THE  LIBRARY 

OF 

THE  UNIVERSITY 

OF  CALIFORNIA 

LOS  ANGELES 

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SAN  FRANCISCO 
COUNTY  MEDICAL  SOCIETY 


Peroral  Lndoscopy  and 
Laryngeal  Surgery 


BY 

CHLVALILR  JACKSON,  M.  D. 

'rofessor  of    l.aryiigology,    University   of    I'ittsbiirgli ;    Consulting    l.aryngologisl 
Bronchoscopist,     Esophagoscopist,    and    Gastroscopist,    Western    Pennsylvania 
Hospital ;  Laryngologist,  Presbyterian  Hospital ;  Laryngologist,  Eye  and  Ear 
Hospital ;  Consulting  Laryngologist,  Western  Pennsylvania  Hospital  for  the 
Insane;   Consulting  Laryngologist,  Bronchoscopist,   Esophagoscopist  and 
Gastroscopist,   Montetiore    Hospital;   Consulting   Laryngologist,    Bron- 
choscopist, Esophagoscopist  and  Gastroscopist,  St.  Francis  Hospital ; 
Consulting    Laryngologist,    Bronchoscopist,    Esophagoscopist    and 
Gastroscopist,        Passavnnt        Hospital :       Bronchoscopist      and 
Esophagoscopist,  Allegheny  General  Hospital;   Bronchoscopist 
and     I'.sophagoscopist,     Pittslwrgh     Hospital     for    Cliililrcn. 


WITH  SIX  COLOKKD  PLATES  AND 
490  ILIA  S'l'KATIONS. 


SAINT  LOUIS.  MO..  U.  5.  A. 

THE.  LARYNGOSCOPE  COMPANY,  PUBLISHERS. 

1915 


Copyright,  ]!tM 
By  Chkvai.ikr  Jackson. 
All  Rights  Reservkd. 


Unrr 

HIS" 


To 

Mv    MoTHliR 

T(i  W'liosK  IxTi':Ri;s'r  in  Mkdical  Scienck 
Till';  AuTHciR  (JwEs  His  Incicmui':, 


And  to 

Mv  Fatiikk 

WiiosK  Constant  Advici:  to 

■'Edl'cati-:  Till-;  Evic  and  tiu-;  Fingi;ks" 

Si-i'RRKD  Tin;  Altiior  to  Continual  Ei'i-ort, 

Tins  Book  is  Atfectionatkly  Dkdicaticd. 


^^4i^86 


Preface. 


A  number  of  repetitions  of  fundamental  facts  have  been  necessary 
in  order  to  facilitate  ready  reference  in  the  limited  time  available  for 
the  busy  surgeon  without  perusing  the  entire  book.  But,  as  full  repeti- 
tir)ns  were  ini]>ossible.  it  is  hojied  IJiat.  for  full  coniprehcnsidn,  the  en- 
tire book  shall  have  been  previously  read.  Symi)toms  are  referred  to 
only  in  so  far  as  they  concern  indications  or  contraindications  for  endo- 
scopy. Diagnosis  is  referred  to  only  in  so  far  as  it  is  to  be  made  endo- 
scoi)ically.  .\n  earnest  effort  has  been  made  to  give  due  credit  to  every- 
one so  far  as  possible  within  the  limits  of  a  practical  manual.  This  effort 
resulted  in  such  an  enormous  niunber  of  references  that,  to  sa\e  repeti- 
tion, the  references  are  all  compressed  into  a  numerical  "liibliography  ' 
at  the  end  of  the  hook,  referred  to  in  the  text  as  "Uib."  followed  liy  the 
number.  The  author  cites  his  personal  experiences  for  what  tlie\-  may 
be  worth  ;  and  he  apologizes  for  the  frequency  of  these  citations,  which 
is  necessitated  by  the  newness  of  the  field,  and  the  nature  of  the  book. 
The  French  saying:  "Neither  never  nor  always"  is  particularly  appli- 
cable to  surgery.  The  author  has  tried  to  make  the  use  of  these  words 
as  rare  as  ))ossible  because  "circumstances  alter  cases,"  and  great  injus- 
tice might  follow  dogmatic  assertions.  For  literary  shortcomings,  the 
author  asks  indulgence  because,  even  if  he  were  more  capable,  literary 
work,  as  with  all  clinicians,  is  done  under  stress  of  limited  time  and  op- 
portunity L'niess  otherwise  credited,  the  illustrations  are  jihotograiihic 
reproductions  of  drawings  and  jjaintings  by  the  author  who  solely  is 
responsible  for  illustrative  errors  and  shortcomings. 

Thanks  are  due.  first  of  all,  to  the  great  master,  I'rof.  Killian.  for 
kindlv  consiijcration  .-uid  for  doing  me  the  honor  of  writing  the  Chapter 
on  Sus])ension  Laryngoscopy.  I'dr  the  translation  of  that  Cluijiter  the 
author  is  indebted  lo  Dr.  j.  .\.  llageman.  and  for  editing  the  translation, 
as  well  as  for  valualile  advise  and  assistance,  to  Dr.  M.  .\.  (loldstein. 
I"r)r  aid  in  the  literar\'  work  the  ;u)tlu)r  acknowledges  his  great  obligations 
to  Miss  Josephine  W.  W  bile.  Thanks  are  due  to  Miss  liabette  Kahn 
for  tlie  careful  |)re]iar;ition  of  the  very  comjilete  index,  h'or  the  accuracy 
of  case  records   and    for  assistance  in   all   phases  of   the    work,   clinical 


and  literary,  thanks  are  due  to  that  able  endoscopist.  Dr.  Ellen  J.  Patterson. 
The  author  wishes  here  to  express  his  appreciation  of  tiie  part  taken 
liy  the  following  associates  with  whom  he  has  for  years  worked  shoidder 
to  shoulder  and  without  whose  aid  whatever  measures  of  success  that 
may  have  been  attained  would   have   been   impossible : 

Drs.  Patterson.  P.oyce.  Price,  Clark.  McCready,  Lichtenfels,  McKee, 
Fisher,  Sim][)son.  l^'pham,  Spiro;  Mrs.  P.raddow  ;  Misses  Ketcham.  Saun- 
ders. Eissler,  Bear,  Dice,  Talbot,  Lewellyn,  Symes  and  Piird. 

T-ast,  and  not  the  least  important,  the  author's  thanks  are  due  to 
the  profession,  general  and  special,  at  home  and  abroad,  for  the  clinical 
material  and  the  hearty  support  which  have  rendered  this  book  possible. 
Especial  assurances  of  appreciation  are  due  the  staflfs  of  various  hospitals 
with  which  the  author  was  not  connected,  for  their  broadmindedness  in 
sanctioning  the  author's  aid  in  the  relief  of  ward  sufferers. 

Chevalier  Jackson. 

l^ittsbnrgh,  Pa.,  July,  l'.il4. 


Contents. 


Chapter  I.  Instnimciits. 

Chai)tcr  II.  .\natoni\-. 

Chapter  III.  Preparation  of  the  Patient  f(^r  Peroral   Eiuioscopy. 

Chapter  1\'.  Anesthesia  for  Peroral  Endo-eopy. 

Chapter  \'.  I'.ronclioscopie  Uxygen  Insufflation. 

Chapter  \I.  I'o^iition  of  the  Patient  for  Peroral  Endoscopy. 

Chapter  \  11.  Direct   Laryngoscopy. 

Chapter  \'III.  Suspension  Laryngoscopy. 

Chapter  IX.  Introduction  of  the  Bronchoscope. 

Chapter  -\.  Introduction  of  the  Esophagoscope. 

Chapter  XL  Ac(|uiring   Skill. 

Chai)ter  .XIl.  I'oreign    llodies  in  the  Air  and   I'ood   Passages. 

Chapter  XI  II.      Eoreign    I'.odies   in   the    Larynx    and    Tracheobron- 

chial Tree. 

Chapter  Xl\  .      Remu\al  of  l'"oreign   IJodics  from  the  Larynx. 

Cha])ter  W.     .Mechanical    Problems    of    P.ronchoscopic    Foreign 

P>ody   Extraction. 

Chapter  X\'l.      I'oreign    P.odies    in     the     P.ronchi     for     Prolonged 

Periods. 

Chajiter  X\  11.      L'nsuccessful   Cases   of    llronchoscojiy    for   Foreign 

I'.odies. 

Chapter        X\'11I.      I'oreign  liodies  in  the  Eso]>hagus. 

Chapter  XIX.      I'.sophagoscopy    for   l"oreign    I'.odies. 


Chapter 

XX 

Cliai'tLT 

XXI 

Cliaiiter 

XXII 

Cliaiiter 

xxm 

Chapter 

XXI\' 

Chapter 

XXV 

Chapter 

XX\1 

i>:stri'mi-:nts. 

Plenroscopy. 

XXI.      Ilhistrative  Cases  of  Endoscopy  for  Foreign  RocHes 
in  the  Air  and  Food  Passages. 

Benign  Growths  in  the  Larynx. 

Benign  Growths  IVimary    in    the  Tracheobronchial 
Tree. 

Benign  Xeoplasms  of  tlie  Esophagus. 

Endoscopy  in   Mahgnant  Disease  of  the  Larynx. 

Bronchoscopy     in      .Malignant     Growths     of     the 
Trachea. 

Chapter      XX\'II.      Malignant  Disease  of  the  Esophagus. 

Chapter    XX\"I1I.     I^irect  Lar}'ngosco])y  in  Diseases  of  the  Larvnx. 

Chapter        XXIX.      Bronchoscopy    in     Diseases    of    the    Trachea    and 
Bronchi. 

Chajiter  XXX.  Diseases  of  the  Esophagus. 

Chapter        XXXI.  Diseases  of  the  Esophagus  (Continued). 

Chapter      XXXII.  Diseases  of  the  Esophagus  (  Continued  ). 

Chapter    XXXIll.  Di.'ieases  of  the  Esophagus  (  Continued  ). 

Chapter     XXXIN'.  Diseases  of  the  Esophagus  (  Continued  1. 

Chapter      XX  X\'.  Gastroscopy. 

Chapter     XXX\'I.  External   Lar}ngeal   Surgery. 

Chapter  XXXVII.  Tracheotomy. 

Chapter XXXVIII.  Chronic  Stenosis  of  the  Larynx  and  Trachea. 

Chapter     XXXIX.     Intubational     Dilatation     of     Chronic     Laryngeal 
Stenoses. 

Laryngostomy. 

Decannulation    .\fter    Cure    of    Chronic    Laryngeal 
Stenosis. 

Malignant  Disease  of  the  Larynx. 

?\lalignant  Disease  of  the  Larynx   (Continued). 

Technic  of  Thyrotomy    for   Malignant    Disease   of 
the  Larj'nx. 

Technic  of  Larvngectomv. 


Chapter 

XL, 

Chapter 

XLI, 

Chajiter 

XLII 

Chapter 

XLllI 

Chapter 

XLIV 

Chai>tcr 

XL\' 

Chapter 

XL\"I 

Part  I. 


CHAPTER     I. 

Instruments. 

Since  the  author's  earlier  work  was  ])iiblished  a  large  number 
of  new  instruments  and  modilications  of  old  forms  have  been  devised. 
Each  of  them  is  probably  useful  to  others  besides  the  originators;  but 
it  is  clear  that  there  will  never  be  a  universal  instrument.  Each  endo- 
scopist will  work  successfully  with  those  instruments  to  which  he  is 
accustomed.  ]'>y  this  it  is  not  meant  that  a  wise  selection  is  of  no  im- 
portance: quite  tlie  contrary.  In  general  surgery,  if  knives  are  sliarp, 
instrumental  e(|uipment  is  of  minor  importance.  In  endoscopy,  however, 
the  instrumenlarium  is  an  absolutely  fundamental  element  for  success. 
It  is  no  wonder  that  some  of  the  laryngologists  who  have  taken  up  endos- 
copy have  been  discouraged,  when  one  looks  at  the  miserably  inefticient. 
clumsy  instruments  with  which  their  first  attemi)ts  were  made.  I  n- 
fortunately  there  are  many  bad  mechanics  in  the  world,  an<l  surgeons 
who  have  originated  excellent,  practical  ideas  are  chagrined  to  find  that 
failures  due  to  faulty  workmanship  are  blamed,  not  on  the  incompetent 
mechanic  who  made  the  jiarticular  instrument  that  failed,  but  upon  the 
originator  who  is  getting  excellent  results  from  a  well-made  inslrument 
of  correct  model.  All  long  instruments,  such  as  forceps,  canuulae. 
stylets,  probes,  siionge  holders,  and  tiie  like,  should  be  of  spring  tem- 
pered steel  or  spring  brass  in  order  n(jt  to  get  bent,  as  a  bent  instrument 
is  much  more  dit'licuit  to  manage  accurately.  ( )n  the  other  hand  the 
temper  of  steel  nuist  not  be  so  hard  as  to  risk  bieaking,  which  might 
be  a  disaster.  There  is  a  "ha])py  medium"  in  the  temper  of  steel  that 
a  reliable  workman  can  be  depended  upon  to  produce,  that  will  bend 
slightly  to  extreme  pressure  without  breaking. 

Tubes  and  illuminating/  dcz-iccs.  The  personal  equation  enters  so 
largely  into  the  choice  of  instruments  that  the  author  urges  the  reader 
to  get  for  selection  differently  illuminated  instruments  and  try  them  on 
the  dog.  using  first  the  largest  tubes  ;md  then   tiie  smallest,   keeping  in 


13 


INSTRUMENTS. 


mind  that  it  is  in  the  use  of  small  tubes  that  the  greatest  difficulties 
lie;  and  unfortunately,  most  of  the  cases  encountered  are  in  children 
where  small  tubes  are  obligatory.  All  forms  of  illumination  have  been 
greatly  improved  by  the  development  of  the  tungsten  lamp.  Quite  a 
number  of  new  forms  of  illumination  and  new  tubes  have  been  devised, 
and  they  practically  all  have  done  good  service  in  the  hands  of  skillful 
men.  In  the  statistics  which  the  author  gathered,  there  is  practically 
no  difference  either  in  the  mortality  or  the  percentage  of  successful  re- 
movals of  foreign  bodies  between  the  different  kinds  of  tubes  and  illum- 


W'     .^[.\-i.\-r-i-\-i  1  h  I  I  i  1  ^1  1  I  I  i"i  I  I  I  P°i 


Fig.  I.     Ingals'  bronchoscope  and  open  laryngeal  speculum. 

ination.  Far  more  depended  on  the  individual  skill  of  the  operator.  Doubt- 
less, the  best  instrument  for  each  operator  is  the  one  with  which  he  has 
practiced   most. 

Killian  still  uses  the  Kirstein  headlamp  except  for  demonstration 
purposes.  The  lamp  is  very  much  improved  in  construction  and  has 
enormously  greater  illuminating  power. 

Guisez  has  abandoned  his  triple  endoscopic  headlamp,  and  now  uses 
the  Claar  reflector  (Fig.  ii). 

The  lirimings  sliding  tubes  described  in  the  appendix  of  the  earlier 
book  have  been  much  improved  and  are  extensively  used.  (  Figs.  2.  3. 
and  4.) 


INSTRUMKNTS. 


i; 


D.  R.  Patterson  has  modified  the  JJrunings  tubes  b}'  placinji;  the 
beak  on  the  inner  tube  and  the  cylindrical  end  on  the  outer  tube,  always 
introducing  the  instrument  with  the  distal  end  of  the  inner  tube  ex- 
tended beyond  the  distal  end  of  the  outer  tube. 

Excellent  work  is  being  done  in  Chiari's  clinic  and  elsewhere  with 
Kahler's  bronchoscopes  and  esophagoscopes.  They  are  double  tubes,  one 
sliding  within  the  other  like  the  ISninings  instruments,  but  the  illum- 
inating mechanism  is  different.     (Fig.  8.) 

Schoonmaker  has  devised  an  excellent  sliding  double-tube  broncho- 
scope. 


Figs.  2  and  3.     Brunings'  two  illuminating  handles   for  laryngoscopes,  bron- 
choscopes, and  esophagoscopes. 

Ingals  uses  an  improved  form  of  his  original  distally  illuminated 
bronchoscope  (Fig.  J),  with  which  he  has  done  some  remarkablv  suc- 
cessful work. 

.Mosher  uses  esojiiiagoscopes  of  very  large  transverse  diameter  with 
distal  illumination.     (Fig.  .5.) 

ICfi'orts  to  j)roducc  jointed  and  angular  esophagoscopes  and  gastro- 
scopes  continue,  and  all  such  should  be  encouraged  (provided  great  care 
is  exercised)  because  all  effort  results  in  increased  attention  to  the 
esophagus  and  its  diseases.  There  is  absolutely  no  hope  that  any  eso- 
])hageal  instrument  will  ever  lie  devised  that  will  be  safe  unless  carefully 
used,  because  even  the  soft  rubber  stomach  tube  has  been  known  to  cause 
fatal  perfor.-ition.     (  )ne  of  the  most  successful  of  the  angular  esophago- 


14 


INSTRUMENTS. 


Fig.  4.  Briinings'  spatulae  and  tubes  for  use  with  the  illuminating  handles 
shown  in  the  preceding  illustration.  A,  tube  to  be  attncbed  to  hanaie.  B,  ninci' 
tube  sliding  into  A,  as  shown  at  C,  the  inner  tube  being  locked  at  the  required 
depth  by  the  ratchet  shown  at  D.     The  other  illustrations  are  laryngeal  spatulae. 


Fi... 
duction. 


\  ^\   \  5\    \  -\  \  '\   \  A    \  -\   \  -\   \  -\   \  "V  \  A  \  "V^W^.^ 


t 


s> 


2) 


Moshcr's  e^ophaposcopc   sliowing  distal  light  and  mandrin   for  intro- 


IN'STRUMEN'i'S. 


15 


scopes  is  the  indirect  one  of  Lewisohn.  The  author  saw  it  passetl  upon 
a  patient  with  practically  no  discomfort  and  the  view  was  good.  In  its 
present  form  it  is,  of  course,  adapted  to  sim])le  inspection,  not   for  the 


I 


^^f^ 


1    ■  •  •  I    •  .  •  I  ■  •  ■  •  I  ■  ■  •  ■  I  ■  ■  ■  ■  I '  •  • '  ■ .'  ■  ■ 


m^ 


-(^^ 


Fk;,  ().  Giiisiz's  e.<cii)liai;oscoiit,  (luiscz,  as  .shown  in  the  imner  iUii'trjition. 
uses  a  Claar  headlight  for  illumination  and  a  soft-ended  inandiin  for  introduction 
as  shown  in  tlie  Icjwer  illustration. 


removal   of   foreign   bodies  or  sjiecimens,  nor   for  prcihing  or  palpation, 
wi])ing  or  medication. 

A  nimilicr  of  laryngeal   specvdae  have  been   di\ised.     Ingals'    (Fig. 
1),    Hill's    (Fig.    9),    Dickinson's    (Fig.    13),    and    I'ratt's    use    a    dis- 


16 


IXSTRUMEXTS. 


tal  light.  Pratt's  has  a  battery  contained  in  the  handle  Richartl  H. 
Johnston  prefers  a  narrow  tube  and  has  done  wonderful  work  with  the 
author's  original  tubular  speculum  (Fig.  (i,  p.  19,  of  the  earlier  book, 
IJib.  2()9).  Johnston  attached  a  handle  as  shown  in  Fig.  11.  Mosher 
devised  an  open  speculum  for  use  with  the  headlight  or  head  mirror, 
Fig.  12.  The  Boyce  speculum  is  (]uite  simple  and  eflfective  when  used 
with  the  Wendell  C.  Phillips  headlight,  worn  between  the  eyes,  w-here 
the  luminous  and  visual  axes  almost  correspond. 


THE  AUTHORS   IXSTRUMEXTS. 


LaiyHf/oscof^cs.      The    laryngeal    speculum    or    direct    lar}-ngoscope 
(Fig.   14)   devised  by  the  author  in   1903  and   shown  in  Fig.  7  of  the 


Fig.  ".     Yankauer's  laryngeal  tube-spatula. 

earlier  book  (P)ib.  2()9)  has  been  found  to  answer  all  requirements  for 
direct  laryngoscopv  so  well  that  the  atuhor  has  made  no  modifications, 
excejjt  that,  at  the  suggestion  of  R.  H.  Johnston  the  handle  is  now  made 
detachable.  This  instrument  has  received  various  names :  laryngeal 
speculum,  slide  speculum,  direct  laryngoscope,  etc.  Being  us.ed  for  ex- 
.amination  of  the  larynx,  it  would  seem  that  the  now  generally  used 
term  "lan^ngoscope"  is  preferable.  The  method  of  introducing  broncho- 
scopes through  this  laryngoscope  has  the  great  advantage  that  nc>  septic 
instrument  need  be  introduced  into  the  trachea,  because,  as  abundantly 
proven  by  laljoratory  examinations  of  secretions  withdrawn  from  the 
bronchi  through  the  bronchoscope,  the  bronchoscope  need  not  be  con- 
taminated in  introduction.  Laboratory  work  has  shown  that  there  is, 
under  normal  conditions,  a  sharp  line  of  limitation  of  oral  sepsis  at  the 


INSTRUMRNTS. 


17 


orifice  of  the  larynx.  The  first  form  of  laryngoscope  used  by  the  author 
was  modeled  after  the  original  Kirstein  ''autoscope"  which  had  its  trans- 
verse greater  than  its  vertical  diameter.  A  double  handle  was  attached 
to  a  simple  oval  tube  with  half  its  periphery  cut  away  for  the  distal  two- 
thirds  of  its  length  (Fig.  15).  Then,  after  Killian  created  hronchoscopv, 
the  author  added  a  slide  at  the  side  for  bronchoscopy.     Pioth  of  these 


Fig.  8.  Kaliler  panelectroscolie.  The  tulics  used  with  this  arc  similar  to  the 
sliding  tubes  of  Briinings.  The  rays  of  light  from  the  lamp,  h,  are  rcHccted  by  the 
mirror,  g,  into  the  tulie,  e.  The  endnscopist's  eye  is  placed  at  the  notch  in  the 
mirror,  g.  The  mirror  can  be  thrown  out  of  the  way  for  the  introduction  of  in- 
struments hy  pressure  of  the  tluimli  on  the  arm,  c. 


laryngoscopes  were  used  with  the  ordinar_\-  head-mirror,  and  witli  the 
Wendell  C.  Phillips  head-lamp  worn  between  the  eyes.  As  the  author 
found  the  oval  lumen  less  convenient  than  the  round  for  working  at  the 
side  instead  of  over  the  dorsum  fif  the  tongue,  as  he  fre(|ucntlv  wished 
to  do.  he  abandoned  the  n\al  lumen   for  the  niund  lumen   with  the  slide 


18 


INSTRUMENTS. 


Fig.  9.     Hill's  modification  of  the  Chevalier  Jackson  laryngoscope. 


3Q  CCHVMCTRCS ->i 

Fig.  10.     Hill's  esophagoscopc. 


Fig.  II.  The  author's  tubular  speculum  to  which  Dr.  Richard  H.  Johnston 
added  the  laryngoscope  detachable  handle  (A),  preferring  this  narrow  tube  to  the 
wider  laryngoscope  tube.  At  the  left  Dr.  Johnston  is  using  the  tubular  speculum 
with  handle  detached,  the  patient  being  in  the  straight  position,  witliout  extenson 
of  the  head. 


INSTRL'MKNTS. 


19 


at  the  side.  As  the  edges  of  tlie  shde  were  then  made  the\'  became  rough 
in  use,  and  to  {jrevent  this  the  sHde  was  moved  to  the  top  and  in  tliis 
form,  witli  the  addition  of  the  light  carrier  of  the  Einliorn  esoi)hagoscope, 
it  has  been  in  general  use  ever  since.  Recently  some  men  who  have  done 
the  author  the  honor  to  work  with  him  ha\e   found  the  oval  model  so 


Fig.  12.    Mosher's  laryngeal  spatula  with  dental  protector. 


Fig.   i.v     Ij.  M.   Dickinson's  larynKOSCopc. 

convenient  for  the  introduction  of  esoi)hagosco])es.  lironchoscopes,  and 
es[)ecially  intratracheal  insufflation  tubes,  that  it  has  iieen  deemed  worth 
while  to  re-urrert  the  o\al  mnikl.  Tlu-  .slide  can  be  left  off  altogether 
and  thus  removal  of  the  laryngcjscojie  after  introduction  of  tubes  of  all 
kinds  is  facilitated,  as  in  the  Dickinsun  siieculum.  The  o\al  lumen, 
giving   a    larger   fiel.d.    has   the   additional    advantage   of    facilitating    the 


20 


I.NSl'KL'.MHiN'TS. 


identifications  of  land-marks  and  of  affording  more  room  for  endo- 
laryngeal  operations.  Probably  many  operators  will  prefer  working 
through  the  oval  laryngoscope  to  the  method  that  has  seemed  easiest  to 
me:  namely,  using  the  round  lumen  laryngoscope  for  vision  only,  the 
forceps  and  other  instruments  being  passed  alongside  the  laryngoscope. 

The  width  of  the  oval  lumen  laryngoscope  will  be  found  greatly  to 
increase  the  difticulty  of  exposing  the  anterior  commissure.  Everything 
considered,  the  regular  laryngoscope  (Fig.  14)  will  be  found  preferable. 


I 


J 


Fig.  14.  Author's  separable  speculum  for  passing  bronchoscupes  and  lor  di- 
rect laryngoscopy.  This  instrument,  also  called  "direct  laryngoscope,"  laryngeal 
speculum,  etc.,  has  been  found  perfectly  satisfactory  without  modilication  in 
size  or  shape.  Two  sizes  are  needed,  one  for  adults  and  one  for  children.  The  au- 
thor personally  never  used  the  handle,  A.  B.,  in  the  child's  size  instrument,  (sub- 
stituting a  hooked  end)  because  he  always  examines  children  recumbent.  For  endos- 
copists who  use  the  sitting  position  for  children  the  handle  is  a  great  advantage. 
A  number  of  modifications  have  been  made  by  varioua  endoscopists  to  suit  their 
individual  requirements.  (Illustration  reproduced  from  the  author's  earlier  volume.*) 

Bronchoscopes.  In  bronchoscopes  the  author  has  been  unable  to  im- 
prove on  the  light,  simple,  well-illuminated  instrument  shown  in  Fig.  1(>. 
His  only  failures  to  remove  foreign  bodies  from  the  bronchi  since  com- 
mencing to  use  this  instrument  a  number  of  years  ago,  were  due  to  fail- 
ures to  find  four  pins  which  were  in  minute  bronchi  beyond  the  limits 
reachable  by  a  1  mm.  tube,  in  other  words,  beyond  the  limits  of  bronchos- 
copy.   In  no  instance  has  this  bronchoscope  been  found  wanting. 

Four  sizes  are  sufficient  for  every  possible  case  from  a  new-born  in- 
fant to  the  largest  adult. 

•Tracheo-bronchoscopy,  Esophagoscopy  .and  Gastroscopy.  PubUshed  at  St. 
Louis,   1907. 


IXSTRUMKNTS. 


21 


The  selection  of  a  tube  for  the  particular  case  no  longer  presents  the 
difficulties  that  it  did  when  a  large  number  of  tubes  of  various  lengths 
were  thought  to  be  necessary.  The  bronchoscopes  and  esophagoscopes 
can,  as  a  rule,  be  selected  absolutely  by  the  ages  mentioned  in  the  given 
list.  Naturally  there  is  a  border-line  between  the  older  child  and  the 
young  adult,  where  a  slightly  larger  size  than  the  child's  size  could  be 
used  where  the  adult  instruments  are  slightly  too  large.  In  the  case  of 
the  bronchoscope,  this  field  is  fully  covered  by  the  7  mm.  instrument, 
which  can  be  used  in  such  cases,  and  is  plenty  large  enough  for  work  in 
an  adult  also,  though  for  adults  of  average-sized  larynx  and  trachea  it  is 
much  better  to  have  the  !1  mm.  bronchoscope,  as  it  gives  a  much  larger 


Fig,  15.  Form  of  the  first  of  the  author's  laryngoscopes  originally  used  with 
the  Wendell  C.  Thillips  headlight.  Here  shown  with  Einhorn  li.ght  carrier  add- 
ed. The  slide  at  the  side  can  he  left  off  altogether,  if  desired,  to  facilitate  the  re- 
moval of  the  laryngoscope  after  the  insertion  of  Ijronchoscopes,  intratracheal  in- 
sufflation anesthesia  catheters,  etc.    The  instrument  shown  in  Fig.  14  is  prcfcralile. 


field  of  view.  In  cases  where  it  is  desired  to  enter  a  ver)-  small  branch 
bronchus,  low  down,  it  would  be  necessary  to  use  the  7x10  bronchoscope 
in  an  adult.  In  children  under  one  year  of  age  the  T)  mm.  bronchoscope, 
is  used  by  many  .American  bronchoscopists,  but  as  it  does  not 
ordinarily  go  through  easily,  some  traumatism  may  be  done  to 
the  lar>nx  which  will  result  afterward  in  subglottic  edema.  The 
author  and  Dr.  b.lkn  J.  Patterson  always  use,  in  such  cases,  4  mm. 
bronchoscojies,  through  the  mouth ;  but  to  those  who  have  not  practiced 
work  with  small  tubes,  this  may  ])rove  rather  difficult.  From  one  to  five 
years  of  age,  a  ")  mm.  l)ronchoscope  will  be  found  perfectly  satisfactory 
for  use  through  tl;e  larynx.     .\t  six  years  of  age  and  over,  the  7  mm. 


INSTKUMHNTS. 


bronchoscope  can  be  used  through  the  larynx  without  risk  of  subglottic 
edema,  if  none  has  existed  prior  to  the  bronchoscopy,  and  if  manipula- 
tions be  gentle. 


^ 


Fig.  i6.  Author's  lircmchoscope  as  originally  devised.  The  author  has  had 
adried  to  this  the  small  hranch  tube  suggested  by  T.  Drysdale  Buchanan.  (Fig. 
17).  The  slanted  tulie  mouth  gives  a  lip  that  not  only  facilitates  introduction,  but 
has  manifold  uses.  All  of  the  author's  tubes  are  fitted  with  "cold"  lamps,  which 
lie  in  a  recess  out  of  harm's  way  and  out  of  the  line  of  vision,  .\spirating  canals 
were  found  occasionally  useful  before  the  author  developed  his  "sponge-pumping" 
method  of  removing  secretions. 


r^ 


Fig.  17.  Dosimetric  anesthetizing  attachment  for  the  bronchoscope.  Devised 
by  Dr.  T.  Drysdale  Buchanan.  The  small  branch  tube  ends  in  the  lumen  of  the 
bronchoscope,  and  not  in  an  auxiliary  canal.  All  of  the  author's  bronchoscopes  are 
now  made  with  this  small  liranch  tube,  as  it  has  been  found  very  useful  for  bron- 
choscopic  oxygen  insutTlation. 


If  inslnimcnts  are  selected  by  the  tjiven  suggestions,  as  to  sizes,  there 
will  nexx'r  be  any  nee<l  for  withdraw  ing  one  bronchoscope  and  replacing  it 
with  a  different  size.  Should  there  be  any  trouble  with  the  lamp,  which 
shfjuld  not  occur  more  than  once  or  twice  in  a  hundred  bronchoscopies, 


IXSTRUMKNTS. 


23 


the  lamp  can  be  withdrawn  with  the  hght  carrier  and  replaced  by  a  new 
one,  without  removing  the  bronchoscope.  With  the  proper  use  of  the 
sponges  shown  in  Fig.  ■<;T.  the  light  carrier  never  need  be  withdrawn  for 
the  purpose  of  cleaning  the  lamp,  as  the  sponges  wipe  the  lamp  clean  at 
the  same  time  that  they  are  used  for  removing  secretions  from  the  field 
of  vision,  as  shown  in  Fig.  25.  One  of  the  author's  assistants  has  called 
attention  to  the  fact  that  it  was  unnecessary  to  remove  a  light  carrier 
once  in  72  consecutive  cases.  Secretions  never  bake  on  the  lamp  because 
the  lamp  does  not  get  hot.  The  lamp  is  in  a  recess  out  of  the  way  of 
instruments,  so  that  it  cannot  be  broken  and  cannot  get  caught  on  sponges. 
The  objections  raised  by  operators  who  have  never  used  distal  illu- 
mination are  unjust.     One  statement  made  thai  the  distal  light  is  quickly 


Fig.    iS.     Author's   special   small-ended   liionclioscope    for    examining   the   ori- 
fices of  very  small  bronchi.     Xot  intended  for  regular  work  upon  ordinary  cases. 


obscured  by  blood  and  secretions  is  based  ])iuely  on  theory.  The  author, 
as  is  well  known  by  all  who  have  honored  his  clinic  wilii  a  visit,  works 
for  hours  at  a  time  without  one  moment's  interruption  for  removal  or 
cleansing  of  lamps  other  than  the  regular  swabbing  that  is  necessary  for 
the  remow'il  of  secretion  from  tlie  field  with  any  fnnn  of  illumination,  it 
is  impossible  lo  see,  with  any  form  of  instrument,  ihrotigh  a  pool  of  se- 
cretions. 

Bsophagoscopes.  The  author  has  m;ide  no  changes  whatever  in  the 
esophagosco])e  devised  by  iiiin  in  11M)1.  lie  has,  however,  abandoned  the 
use  of  the  mandrin  altogether,  the  instrument  being  always  passed  by 
sight  and  the  matnirin  is  never  used  unless  it  is  desired  to  hold  it  on  the 
outside  of  a  ])atient  to  determine  the  point  on  the  surface  corresponding 
lo  the  dei)th  of  insertion  of  the  tube.     For  this  ])urpose,  the  mandrin  gives 


24 


INSTRUMENTS. 


the  exact  length  of  the  esophagoscope,  and  by  holding  it  parallel  to  the 
esophagoscope,  as  indicated  by  the  portion  of  the  esophagoscope  not  yet 
inserted,  a  point  can  be  found  on  the  skin-surface  of  the  chest  or  epi- 
gastrium that  will  correspond  precisely  to  the  distal  end  of  the  esophago- 
scope. The  esophagoscope  is  always  passed  by  sight,  absolutely  never 
any  other  way,  for  the  following  reasons:  1.  Once  the  knack  is  ac- 
quired, it  is  just  as  easy  to  pass  by  sight.  2.  In  foreign-body  cases,  if  a 
mandrin  be  used  the  foreign  body,  if  small,  is  very  apt  to  be  overridden 
before  the  operator  realizes  that  the  distal  end  has  reached  the  position 


Fig.  19.  The  author's  esophagoscope  and  gastroscope  with  distal  light  and 
drainage  canal.  An  obturator  is  provided  but  is  never  used  by  the  author.  Only 
two  sizes  are  needed.  10  mm.  x  53  cm.  for  adults.  7  mm.  x  45  cm.  for  children. 
Shorter  sizes  are  made  but  are  not  used  by  the  author  because  with  the  distal  light 
there  is  no  advantage  in  a  short  tube.  This  esophagoscope  has  been  in  constant  use 
for  10  years  and  has  been  found  to  be  in  every  way  satisfactory  without  modifica- 
tion. The  slanted  end  added  (Fig.  426),  for  special  purposes,  facilitates  introduc- 
tion. 


Fig.  20.     Window-plug  for  occluding  the  proximal  tube-mouth  when  it  is  de- 
sired to  balloon  the  esophagus  or  stomach,  as  su,ggested  by  Mosher. 


of  the  foreign  body.  3.  There  may  be  in  any  case,  lesions  of  the  eso- 
phagus that  can  be  seen  and  avoided,  provided  the  instrument  is  being 
passed  by  sight.  4.  The  importance  of  the  use  of  the  open  tube  passed 
by  sight  in  foreign-body  extractions  is  so  great  that  it  is  important  that 
all  esophagoscopies  should  be  done  in  that  manner,  in  order  that  skill 
may  be  ac(|uired,  so  that  when  foreign-body  cases  are  met  with,  the  pass- 
age by  sight  will  be  easy.  If  this  knack  is  not  acquired,  it  is  very  much 
more  difticult  to  pass  by  sight  than  with  a  mandrin. 


INSTRUMENTS.  25 

An  esophagoscope  willi  a  slanted  end  similar  to  the  bronchoscope 
(Fig.  IG),  is  useful  for  finding  the  subdiverticular  opening,  and  for  solv- 
ing some  of  the  mechanical  problems  of  foreign-body  extraction.  It  has 
no  holes  in  the  side  and  is  longer  and  larger  in  diameter  than  the  bnmcho- 
scope.     (Fig.  -J2(i). 

Complicated  forms  of  tubes  with  extracting,  excising,  and  dilating 
attachments  have  not  seemed  to  the  author  as  generally  applicable  as  plain 
tubes  through  which,  by  manual  manipulations,  any  procedure  can  be 
carried  out  with  appropriate,  independent  instruments. 

Measuring  rule.  It  is  customary  with  esophagoscopists  to  measure 
distance  from  the  upper  teeth.  Some  esophagoscopcs  have  graduations 
marked  on  the  outside.  The  author's  tubes  are  too  thin  and  light  for  this, 
and  moreover,  a  smooth  exterior  is  a  great  advantage.  Therefore,  he 
uses  a  2")  cm.  steel  rule,   (^obtainable  at  any  machinist's  supply  house), 


r 


i-,i^^ 


} 


'^ 


Fig.  21.  Esophageal  speciihim  for  foreign  l)ody  work  and  for  operations  upon 
the  upper  end  of  the  esophagus.  This  instrument,  by  detaching  the  handle,  becomes 
a  very  efficient  pleuroscope  because  of  the  facility  with  which  tlie  flopping  lung  can 
be  controlled.  It  can  be  thoroughly  sterilized.  The  child's  size  is  an  excellent 
laryngoscope  and  subglottic  laryngoscope  for  adults. 


which  is  sterilized  with  the  instruments  and  kept  on  the  sterile  instru- 
ment table.  When  the  tube-mouth  is  at  the  lesion,  an  assistant  places  one 
end  of  the  rule  at  the  upper  teeth  (or  alveolus  if  teeth  are  absent)  and  the 
distance  to  the  proximal  end  of  the  esophagoscope  is  marked  by  holding 
the  thumb  at  the  i)oint.  The  measurement  is  subtracted  from  the  known 
tube  length.  Thus,  wdien  20  cm.  of  the  5:?  cm.  esophagoscope  projects 
proximally  from  the  teeth  the  lesion  is  known  to  be  'M  cm.  from  the  U])- 
per  teeth.  If  it  is  desired  to  locate  this  point  externally  on  the  patient's 
chest  after  the  esophagoscope  is  withdrawn,  the  patient  sitting  erect  is 
told  to  look  at  the  ceiling  and  the  23  cm.  is  measured  downward  from 
the  upper  teeth,  and  a  mark  is  made  on  the  skin  of  the  client.  The  same 
method  is  used  in  bronchoscopy. 


2()  INSTRUMENTS. 

Esophageal  speculum.  For  dealing  with  foreign  bodies  and  disease 
high  up  in  the  esophagus,  the  author  has  found  an  elongation  of  his 
laryngeal  speculum  exceedingly  useful.  This  instrument  is  25  cm.  long 
for  use  in  adults.  K!  cm.  for  children,  and  with  these  instrimients  there 
is  very  much  less  risk  of  overriding  foreign  bodies  in  the  high  situation 
than  with  the  esophagoscope.  This  esophageal  speculum  has  also  been 
found  particularly  useful  for  the  breaking  up  of  those  rare  congenital 
webs  first  described  by  Mosher  and  Clark,  and  of  the  high  strictures  of 
the  esophagus  following  decubitus  idcers  resulting  from  the  mixed  infec- 
tions complicating  enteric  fever,  scarlatina,  diphtheria  and  like  conditions, 
and  those  following  gummata.  These  webs  and  strictures  yield 
quite  readily  to  the  breaking  up  and  stretching  with  this  speculum. 
Cicatricial  stenoses,  especially  those  following  the  breaking  down  of  gum- 
mata, have  a  tendency  to  recur,  and  it  is  necessary  to  repeat  the  treat- 
ment frequently,  but  in  some  of  the  conditions  a  very  few  treatments  are 
sufficient,  a  divulser  being  occasionally  reciuired.  Intricate  instrumenta- 
tion, when  needed,  is  greatlv  facilitated  by  the  wide  exposure  afforded. 

In  foreign  body  work  it  has  seemed  to  the  author  to  be  preferable 
to  an  esophagoscope  for  the  removal  of  foreign  bodies  at  their  favorite 
site  of  lodgment  just  above  the  upper  thoracic  aperture.  Foreign  bodies 
in  this  location  are  much  more  apt  to  be  overridden  by  the  esophagoscope 
than  by  this  speculum.  Of  course  at  the  mouth  of  the  esophagus,  the 
cricopharyngeus,  coming  out  from  the  posterior  wall,  has  a  tendency  to  ob- 
struct the  view :  and  this  must  be  repressed  posteriorly  bv  an  elongated 
Mosher  alligator  forceps.  (Plate  III,  Fig.  10.)  The  speculum  can  be 
used  in  either  the  recumbent  or  the  sitting  position  of  the  patient.  It  is 
made  in  two  sizes,  one  for  adults  and  one  for  children.  The  child's  size 
makes  an  excellent  adult  laryngoscope,  especially  for  those  who  prefer 
a  narrow  spatular  end.  It  also  makes  an  excellent  subglottic  laryngo- 
scope for  adults,  as  the  relatively  narrow  spatular  end  can  be  readilv  in- 
serted through  the  glottic  chink. 

Batteries.  Xo  practical  eft'ort  has  yet  Ijeen  made  to  ada]jt  the  tallow 
candle  or  a  kerosene  lamp  to  endoscopy.  We  are  compelled  to  use  elec- 
tric light  of  some  kind.  If  the  endoscopist  is  not  of  a  sufficiently  mechan- 
ical turn  of  mind  to  keep  his  electric  lights  burning  properly,  no  matter 
what  form  of  instrument  he  uses,  he  will  not  have  the  greatest  success  in 
foreign-body  work,  for  endoscopic  extraction  is  a  ([uestion  of  mechanics 
from  beginning  to  end.  It  does  not  require  great  brain  power  or  high  in- 
tellect, but  in  some  cases  mechanical  ingenuity  is  taxed  to  the  utmost  to 
get  out  the  foreign  body  without  interfering  with  breathing  and  without 
traumatism  to  the  tissues.  If  the  surgeon  is  not  a  mechanical  genius,  he 
should  have  a  trained  surgical  assistant  who  has  the  necessarv  mechanical 


INSTKUMEXTS. 


27 


ability.  The  sim|)lest,  best  and  safest  source  of  current  is  a  double  dry 
batter}'  arranged  in  two  groups  of  four  cells  each.  Each  set  should  have 
two  liinding  posts  and  a  rheostat.  I'ailure  will  result  from  an  attempt  to 
work  with  makeshift  batteries,  the  current  from  which,  with  onlv  a  cell 
selector  for  control,  jumps  up  from  underillumination  to  overillumination 
and  burns  out  the  lamps.  Ingals,  who  is  a  leading  authority  on  bronchos- 
copy, and  the  author  concur  in  the  lielief  that  all  forms  of  rheostats 
devised  for  adapting  commercial  circuits  to  tube  work  involve  a  certain 
degree  of  risk  because  of  the  tube  which  makes  a  moist  contact  with 
tissues  so  close  to  more  or  less  of  the  course  of  tb.e  vagi.     .\o  matter  how 


Fig.  22.  Author's  endoscopic  battery  heavily  built  lor  rclialiility.  It  contains  8 
-dry  ce^ls,  series-connected  in  2  groups  of  4  cells  eacli.  ICacli  group  has  its  own 
rheostat  and  i)air  of  binding  posts. 

tliorough  the  construction,  lliere  is  always  a  jiossiliility  of  "grounding  of 
the  circuit  through  the  handle,  tube,  and  jiatient.  This  danger  is  present, 
whether  the  lighting  is  proximally  or  distally  a|)plied.  These  remarks  <lo 
not  api)ly,  of  course,  to  the  Kirslein  lamp  such  as  was  originally  used  by 
Killian,  and  such  as  he  still  uses  for  all  work  other  than  demonstration. 
Tills  lamp,  being  on  the  forehead  of  the  operator,  there  is  no  chance  of  the 
current  being  communicated  to  the  bronchoscope  or  esophagoscojic.  The 
O[)crator  may.  at  times,  get  a  portion  of  the  current  on  his  head,  but  tliis 
being  on  the  skin  surface  is  of  no  consequence,  and  is  a  \ery  different 
matter  from  the  long  moist  contact  of  large  area  throughout  nearly  the 
full  length  of  both  vagi.  The  author  is  delighted  to  have  the  support  of 
so  eminent  an  authority  as  Ingals.  (  I'ib.  'Z'H\).  The  atithor's  objection  has 


28  INSTRUMICNTS. 

been  altogether  theoretical,  but  Ingals  has  actually  seen  the  sparking  due 
to  "short  circuiting."  The  author  has  always  used  batteries  and  has 
found  them  quite  satisfactory.  All  operators  who  have  had  any  trouble 
with  batteries  have  been  working  with  an  equipment  that  is  not  of  sub- 
stantial character.  Tn  his  early  days,  the  author  had  much  trouble  with 
batteries  which  were  made  in  the  same  flimsy  manner  as  the  ignition  sys- 
tem of  the  early  automobiles.  In  the  latter,  freedom  from  trouble  only 
came  with  heavy  solid  construction.  With  this  in  view,  the  author  had 
built  by  Mr.  Mueller,  a  substantial  battery,  the  construction  of  which 
should  be  beyond  failure.  (Fig.  22).  It  contains  two  sets  of  four  cells 
each  of  the  ordinary  dry  battery,  which  can  be  obtained  anywhere,  day  or 
night,  Sundays  and  holidays,  at  any  garage.  It  is  free  from  the  objection 
to  the  storage  battery  that,  once  exhausted,  requires  a  number  of  hours 
for  recharging.  It  takes  but  a  moment  to  put  in  new  cells.  Dr.  Ellen  J. 
Patterson  and  the  author  have  two  of  these  batteries  and  in  an  experi- 
ence of  thousands  of  cases,  they  have  never  yet  failed  to  obtain  a  light, 
nor  has  any  bronchoscopy,  esophagoscopy,  or  direct  laryngoscopy  failed 
or  been  delayed  for  w-ant  of  illumination.  The  cells  are  changed  once 
every  three  months  without  waiting  for  them  to  deteriorate.  Small, 
flimsy  batteries,  and  especially  pocket  batteries  are  a  delusion  and  a  snare, 
and  their  use  for  endoscopy  is  an  injustice  to  the  patient.  \\'here  the 
speculum  is  used  solely  for  direct  laryngoscopy,  or  in  the  introduction  of 
silk-woven  insufl^lation  catheters  which  are  non-conductors  the  author 
believes  that  the  tise  of  commercial  circuits  with  good  rheostats  is  harm- 
less, because  the  small  area  of  contact  at  the  base  of  the  tongue  involves 
no  serious  risk,  but  personally  he  prefers  batteries. 

Aspirators.  Many  new  forms  of  aspirators  have  been  devised.  For 
the  removal  of  secretions  Yankauer  has  perfected  an  aspirator  operated 
by  a  small  exhaust-fan  in  connection  with  an  electric  motor.  He  has  al- 
so used  a  jet  of  compressed  air  blowing  sidewise  across  the  proximal 
tube-mouth  to  blow  away  the  secretions  coughed  out  by  the  patient  to 
prevent  them  soiling  the  mirror  of  the  Briinings  lamp  or  Kirstein  head- 
light, and  to  prevent  them  reaching  the  endoscopist's  face.  Ingals  uses 
an  electric  aspirating  pump  originally  devised  for  massage  of  the  ear.  A 
number  of  endoscopists  are  using  various  forms  of  aspirators  attached  to  a 
water- faucet.  In  using  these,  it  is  necessary  to  exercise  precaution  if  com- 
mercial circuits  are  used  for  illumination,  lest  the  current  be  "grounded" 
through  the  water  pipes,  especially  when  withdrawing  long  asjiirating 
tubes.  The  author  [^refers,  for  esophagoscopy,  an  aspirating  canal  in  the 
wall  of  the  esophagoscope  or  gastroscope,  the  exhaust  being  by  an  as- 
[lirating  syrmge.  (Fig.  23.)  The  jiositive  pressure-side  of  the  syringe 
also  has  a  soft  rubber  tube,  and  in  case  the  aspirating  c;mal  in  the  wall 


IXSTRUMKNTS. 


20 


of  the  esophagoscope  becomes  obstructed,  a  change  of  the  soft  rubber 
tube  from  the  negative  pressure  to  the  positive  pressure  will  force  out 
any  clots  or  other  obstructions  which  may  have  entered  the  canal.  Con- 
trary to  many  of  the  statements  that  have  appeared,  the  form  of  aspira- 
tion used  by  the  author  has  absolutely  nothing  to  do  with  distal  illumina- 
tion. There  is  no  form  of  illumination  that  will  enable  the  operator  to 
see  through  a  pool  of  blood  and  secretion.  How  to  remove  the  fluid  in 
the  least  possible  time  is  the  study  of  all  endoscopists,  and  the  aspirator 


Fig.  23.  Aspirator  for  esophagoscopy  with  additional  tube  connected  with  the 
plus  pressure  side  for  use  in  case  of  occlusion  of  the  esophageal  drainage  tube. 
This  aspirator  is  much  more  efficient  than  any  soft  rubber-ball  aspirator  can  pos- 
sibly be. 


Fig.  24.  Nozzle  fur  attaching  to  the  aspirator,  for  freeing  the  fauces  and 
pharynx  from  secretion  which  otherwise  would  overflow  into  the  larynx  in  peroral 
endoscopy,  because  the  patient  cannot  swallow  while  endoscopic  tubes  are  in  place. 


in  the  wall  of  the  esophagoscope  is  used  because  there  is  no  inlerrui)tion 
of  the  work.  It  is  a  common  thing  at  a  gastroscopy  to  reinove  a  pint  of 
fluid  without  any  interruption.  An  asi)irating  canal  in  the  tube-wall  can 
never  become  occluded  by  the  indrawing  of  the  mucosa  as  happens  with 
an  inserted  independent  tube,  sometimes  thus  injuring  the  indrawn  mu- 
cosa as  well  as  occluding  the  aspirating  tube.  One  great  advantage  of 
the  syringe  form  of  aspirator  is  its  simi)licity  and  portability.  Most  of 
the  authiir's  work  has  been  done  at  tiie  fourteen  hospitals  of  Pittsburgh, 
and  i)ortability  of  the  entire  instrumentarium  and  organization  made 
work  in  each  as  convenient  as  if  all  work  had  been  done  in  one  institu- 
tion. 


30 


INSTRUMEXTS. 


If  the  patient  is  being  annoyed  with  secretions  overflowing  from  the 
pharynx  into  the  larynx  in  the  recumbent  position,  the  soft  rubber  as- 
pirator tubing  is  detached  from  the  esophagoscope  and  attached  to  the 
curved  metal  tube  (Fig.  24),  which  is  hooked  over  the  upper  alveokis 
(recumbent  patient)  and  the  pharyngeal  secretions  thus  aspirated. 

The  author  does  not  use  any  form  of  aspirator,  either  in  the  wall  of 
the  tube  or  otherwise  in  the  bronchoscope.  He  has  found  that  the  best 
of  all  ways  to  remove  abundant  secretions  and  blood  during  bronchoscopy 
is  to  insert  a  large  swab  on  the  usual  long  Coolidge  sponge-carrier,  push- 
ing it  down  until  the  large  gauze  sponge  goes  beyond  the  distal  end  of 


S.^---/.: :.:..::: 


■i-'Mi. 


Sl^:^:: 


B 


Fig.  25.  Sponge  carrier  with  long  collar  for  carrying  the  small  sponges  shown 
in  Fig.  27.  The  collar  screws  down  as  in  the  Coolidge  cotton  carrier.  About  a 
dozen  of  these  are  needed  and  they  should  all  be  small  enough  to  go  through  the  4 
mm.  (diameter)  bronchoscope  and  long  enough  to  reach  through  the  53  cm.  (lengtlO 
esophagoscope,  so  that  one  set  will  do  for  all  tubes.  The  schema  shows  method  of 
sponging,  The  carrier  C,  armed  with  the  sponge,  S,  when  rotated  as  shown  by  the 
dart,  D,  wipes  the  field,  P,  at  the  same  time  wiping  the  lamp,  L.  The  lamp  does 
not  need  ever  to  be  withdrawn  for  cleaning  during  bronchoscopy.  It  is  protected 
in  a  recess  so  that  it  does  not  catch  in  the  sponges. 

the  bronchoscope.  Then  the  i)ationt  will  cough  the  bronchoscope  full  of 
the  fluid,  and  the  withdrawal  of  the  carrier  and  swab  will  pull  up  often 
as  much  as  an  entire  tube  full  of  secretions  at  a  time,  just  as  the  jilunger 
of  an  ordinary  pump  will  lift  the  water  which  is  above  the  plunger.  This 
is  one  of  the  advantages  in  working  tmder  slight  anesthesia  or  none  at 
all.  This  method  of  aspiration  in  a  case  of  bronchoscopy  with  profuse 
secretion  may  seem  to  the  bystander  to  be  less  efficient  than  would  be  some 
form  of  ptimp,  but  it  must  be  remembered  that  there  is  no  great  pool  of 
secretion  which  can  be  completely  and  permanently  emptied.  The  secre- 
tion is  constantly  being  brought  up  from  the  brcjnchioles  by  the  continued 


INSTRUMENTS. 


31 


coughing  efforts  and  must  hi:  removed  intermittently  from  time  to  time 
as  it  is  brought  up  to  the  neighborhood  of  the  ihstal  end  of  the  tube.  The 
effect  of  the  sponge  is  to  cause  a  fresh  cough  and  to  bring  up  more  se- 
cretion to  tlie  point  where  it  can  be  reached.  Thus  the  continued  swab- 
bing with  the  gauze  sponges  removes  not  only  the  secretion  which  is  al- 
ready in  the  bronchus  which  is  being  explored,  but  it  results  in  the  re- 
moval of  all  the  secretions  from  the  minute  bronchi,  thus  soon  resulting 
in  a  relati\elv  drv  field. 


5 

7 

qand  10 

...  A   .  _. 

f4fb 

4  mm. 

Tubes. 

Fig.  26.  Exact  size  to  wliich  the  bandage-gauze  is  cut  to  make  tiuloscopic 
sponges.  ICach  rectangle  is  the  size  for  the  tulial  diameter  given.  The  dimensions 
of  the  respective  rectangles  are  not  given  because  it  is  easier  lor  the  nurse  or  any- 
one to  cut  a  cardboard  pattern  of  each  size  directly  from  this  drawing.  Tlie  gauze 
rectangles  are  folded  up  endwise  as  shown  at  .-\,  then  once  in  the  middle  as  at  B, 
then  strung  one  dozen  on  a  safety  pin.  In  America  gauze  bandages  run  aliout  16 
threads  to  the  centimeter.  Different  material  might  require  a  slightly  different  size 
and  the  pattern  could  be  made  to  suit. 


Sponge  carrier.  The  author  has  lengthened  the  collar  of  the  Cool- 
idge  cotton  carrier  so  tliat  the  collar  never  catches  on  the  distal  end  of 
the  bronchoscojie  or  esophagoscope  on  withdrawal  of  the  sponge  holder, 
because  the  collar  is  too  long  for  its  proximal  end  to  get  beyond  the  tube- 
mouth.  The  author  uses  in  this  holder  the  small  folded  sponges  shown 
in  Fig.  27. 


32  tNSTRUMENTS. 

Sponges.  Small  squares  cut  from  a  gauze  roller  bandage  (ordinary 
surgical  gauze  is  too  large  in  the  mesh)  and  folded  into  little  pads  and 
strung  onto  a  safety-pin,  as  shown  in  Fig.  37,  before  sterilizing.  These 
are  prepared  beforehand  like  any  other  operating  room  supplies,  packed 
sterile,  and  kept  in  readiness.  Four  sizes  are  needed  for  the  different 
tubes  and  they  are  numbered  on  the  outside  of  the  packages  4.  5,  T,  10. 
They  are  held  securely  in  the  sponge  carrier  shown  in  Fig.  25. 

h'oreign-hody  forceps  Years  of  experience  have  demonstrated  that 
for  foreign-body  work  in  the  larynx  an  alligator  forceps  with  roughened 
jaws,  known  in  America  as  Mosher's,  in  Great  Britain  as  Paterson's,  and 
in  Germany  and  France  as  Mathieu's  forceps,  serve  every  purpose. 
Mathieu's  is  longer  than  the  others  and  hence  is  better  adapted  to  use 
through  the  esophageal  speculum. 

Experience  has  continued  to  demonstrate  the  fact  that  there  is  no 
form  of  forceps  that  has  the  power  and  the  strength  against  breakage 
that  pertains  to  the  tube  forceps.    Hinged-jaw  forceps  are  weakest  at  the 


Fig.  2/.  Manner  of  keeping  endoscopic  sponges.  About  a  dozen  of  one  size  are 
transfixed  on  a  safety  pin,  wrapped,  the  size  marked  on  the  wrapper,  and  then  ster- 
ilized, to  be  opened  onl_v  as  needed.  About  5  dozen  sponges  of  each  of  the  4  sizes 
should  be  kept  on  hand.  Only  one  sponge  is  placed  in  the  sponge-carrier  at  a  time. 
These  sponges  are  made  for  the  author  by  Messrs.  Johnston  and  Johnston,  of  Xew 
Brunswick,  X'.  J.,  and  are  known  as  "bronchoscopic  sponges." 

rivet  and  do  not  begin  to  have  the  strength  of  grip,  nor  the  strength 
against  breakage  when  the  forceps  of  necessity  is  long  and  slender,  as  in 
bronchoscopy  and  esophagoscopy,  though  for  the  larynx  where  a  short 
and  relatively  heavy  and  rigid  instrument  is  required,  the  alligator-jaw 
fulfills  all  purposes. 

Instrument-tnakers.  either  through  carelessness,  or  more  likely  from 
the  taking  of  a  later  and  still  later  instrument  as  a  model,  drift  farther 
and  farther  away  from  the  original  design,  so  that  very  often  the  devisor 
of  an  instrument  can  scarcely  recognize  it  when  it  comes  to  hand.  In 
some  instances  forceps  are  made  so  far  wrong  that  they  will  not  go  in 
the  bronchoscope.  More  often  the  errors  are  in  the  little  details,  such  as 
the  serrations  of  forceps.  Killian  in  his  early  forceps,  such  as  the 
"bean"  forceps  (Fig.  32).  especially  designed  the  serrations  to  have  a 
cant  backward  so  as  to  make  the  forceps  easy  to  push  down  over  a  for- 


in>'i'iu'MI';nts. 


33 


cign  body  but  lo  grip  firmly  on  witlidiawal.  Copying  al'lcr  Killian.  ibc 
author's  early  forceps  were  all  tluis  made  ;  but  instrument  makers  have 
drifted  away  from  the  original  model  until  now  they  are  turned  out  with 
evenly  notched  serrations  that  are  very  smooth  on  the  top  edges  instead 
of  being  sharp  and  canted  as  show^n  in  Fig.  oU.  The  shape  of  serrations 
and  their  action  can  be  readily  understood  by  looking  at  the  lower  feed 
mechanism  of  any  sewing  machine  or  the  gripping-jaw  of  any  pipe- 
wrench.  Such  forceps,  however,  are  capable  of  much  traumatism  if 
carelessly  used,  and  under  no  circumstances  whatever  should  such  a  for- 
ceps be  placed  blindlv  into  a  bronchus  which  is  so  small  that  the  closure 


Fig.  2S.  .\iithur's  universal  handlL'  with  nut-  furm  of  forcign-lHuly  jaws  at- 
tached. Tills  handle  mecliani.sm  is  so  simple  and  delicate  that  the  most  extinisite 
delicacy  of  touch  is  jiossible.  Unfortunately,  instrument  makers  have  often  omitted 
the  little  tliumli  nut  indicated  ahove,  with  the  result  that  the  stylet  was  pulled 
through  when  strong  traction  was  made.  The  cannulae  are  45  cm.  and  60  cm.  long. 
There  is  a  smaller  size  made  for  infant  use,  just  half  of  the  dimensions  except 
those  of  tlie  handle. 


of  llic  forceps  cannot  be  watclied.  ll  blind  groping  in  a  .--niall  broiKlius 
is  ever  justiliable.  it  is  oiil\  so  willi  forceps  whose  serrations  arc  rounded 
and  not  canted.  The  author  prefers  all  inslrunients,  and  especially  fnr- 
ceps.  in  the  lightest  ])ossible  form  consistent  with  the  amount  of  strength 
necessary  plus  a  sunicii-ni  factor  of  safety,  b'urthermore,  for  lightness  of 
touch  it  is  absolutely  necessary  to  dispense  with  springs  to  throw  the 
forcei)S  open.  A  si)riiig-opi)osed  forceps  cannot  possibly  communicate  to 
the  fingers  the  lightness  of  tomb  which  is  essential.  For  general  work, 
the  author  has  never  found  anyliiing  better  than  the  forceps  illustrated 
in  his  first  work  on  bronchoscopy  (  I'.ib.  2iiiM.    The  ring  handles  do  away 


34  INSTRUMENTS. 

with  the  necessity  for  opening  springs.  These  forceps  enable  exceeding 
Hghtness  of  touch  by  which  one  can  easily  tell  if  the  foreign  body  is  prop- 
erly grasped,  and  also  enable  the  endoscopist  to  gauge  precisely  the  de- 
gree of  pressure  that  can  be  applied  without  crushing  the  foreign  body  in 
the  case  of  friable  bodies. 

The  selection  of  the  forceps  for  use  in  a  particular  case  is  a  very 
important  matter  and  concerns  the  mechanical  problems  very  closely.     In 


Fig.  29.     Side-curved  jaws  for  the  author's  forceps.    Reproduced  here  to  em- 
phasize their  usefulness.     (Bih.  269.) 


Fig.  30.  Enlarged  view  of  the  author's  foreign-body  jaws,  showing  proper 
slant  of  serrations  to  prevent  slipping.  This  slant  is  often  lacking  in  the  instru- 
ments in  the  shops. 


Fig.  31.  Schema  showing  test  of  author's  forceps.  If  properly  adjusted,  the 
point  of  the  jaws  of  the  forceps,  F,  w^ill  pick  up  the  epithehum  and  elevate  the  skin 
from  the  palm  of  the  hand  (S)  held  vertically  in  contact  with  the  point  of  the 
forceps  jaws,  when  traction  is  made.  This  shows  that  the  jaws  come  together  first 
at  the  point  in  closing. 


Fig.  32.  Killian's  "bean  forceps"  showing  the  cant  of  the  serrations  to  prevent 
slipping  which  should  be  on  all  foreign-body  forceps.  The  fenestra  are  to  lessen 
the  tendency  to  crush  friable  bodies  like  beans. 

most  instances,  however,  the  plain  jaw-forceps  with  canted  serrations 
shown  in  Fig.  28,  will  serve  everj'  purpose.  Almost  equally 
useful  is  the  side-curved  forceps  shown  in  Fig.  29,  and  if  the  author  were 
limited  to  a  single  forceps,  it  would  be  this  side-curved  form  (Fig.  29). 
The  jaws  projecting  sidewise  are  easily  seen  closing.  .\  large  proportion 
of  the  successful  foreign-body  extractions  by  the  author  have  been  done 


INSTRUMENTS.  35 

with  these  two  forms  of  jaws.     The  exceptions  to  their  use  are  when 
the  foreign  body  must  be  turned  in  order  to  make  the  proper  points  pre- 
sent themselves.     In  the  case  of  pins  and  needles,  the  side-curved  for- 
ceps can  always  be  used  to  cause  presentation  of  the  foreign  body  in  the 
proper  axis  for  removal.     With  irregular  objects,  however,  having  one 
point  sharp  such  as  angular  pieces  of  bone,  it  is  very  necessary  to  disen- 
gage the  foreign  body  near  the  point  with  a  forceps  that  will  permit  rota- 
tion ;  and  for  this  puq)ose,  the  rotation  forceps  shown   in   Fig.  33  are 
ideal,  because  the  points  will  hold  firmly,  yet  will  permit  the  foreign  body 
to  turn  in  the  direction  of  least  resistance.  In  another  class  of  cases  they 
can  be  made  to  throw  the  point  out  from  the  wall  and  into  the  mouth 
of  the  tube  where  the  point  is  shielded  from  doing  damage  to  the  tracheal 
or  esophageal  wall,  as  will  be  explained  in  connection  with  the  mechanical 
problems  of  brpnchoscopic  and  esophagoscopic  extraction  of  foreign  bod- 
ies.   The  author  has  a  separate  handle  for  each  forceps  in  order  that  not 
a  moment  may  be  lost  in  changing  handles  at  a  critical  moment,  should  a 
different  form  of  jaw  be  required.     The  jaws  can  be  adjusted  at  any 
angle,  but  it  is  the  author's  practice  always  to  have  them  open  in  an  up 
and  down  direction,  and  when  other  directions  are  needed,  the  forceps' 
handles  are  turned  in  the  |)njijer  way ;  thus  a  certain  co-ordination  and 
nerve-cell   habit   is  established  by  which   the  operator   always  knows  in 
which  direction  the  jaws  are  opening.    This  facilitates  promptness  in  the 
ocular  endoscopic  recognition  of  the  jaw  movement,  because  the  observ- 
er knows  for  what  to  look.     The  curved-jaw  forceps  should  always  have 
the  curve  to  the  left  of  the  ojjerator.  as  this  is  the  most  convenient  posi- 
tion in  which  to  observe  the  jaws  close  and  to  guide  their  w'ork  with  the 
eye.      I'n  fortunately,    many    instruments    were    turned    out    by    various 
manufacturers  labeled   with  the  author's  name  which   were  heavily  con- 
structed, having  tile  jaws  of  poor  lcnii)cr  and  without  the  very  essential 
little  thumb  nut,  iMg.  2S.  This  omission  may  have  been  ])artly  due  to  the 
fact  that  it  was  not  shown  clearly  on  the  early  illustrations.     This  thumb 
nut  i)ermits  the  o|)crator  to  exert  great  jiower  without  any  danger  of  the 
jaw-stem  pulling  through.    The  screws  at  the  side  are  still  used  in  order 
to  lock  the  jaw-slom  so  that  it  will  push  forward  for  opening  the  jaws. 
Another  misfortune  is  the  fad  that  many  of  these  instruments  are  very 
clumsily  manufactured.     The  author  uses  two  different  strengths  of  for- 
ceps, the  one  reasonably  heavy  for  use  through  all  except  the  very  small- 
est tubes.       For  the  infant  bronchoscopes,  very  lightly  constructed   for- 
ceps are  used  because  great  strength  is  not  necessary.    It  is  necessary  to 
see  the  forceps  close,  and    fur   this  very  slender  forceps  are   required. 
They  are  just  half  the  strength  and  half  the  size,  in  all  dimensions,  of  the 
regular  forcejis,  except  that  the  handle  is  the  regular  size.     They  are  45 
cm.  in  length  of  cannula. 


3G 


IXSTRL'MKXTS. 


Occasionally,  it  is  desired  to  twist  a  foreign  Ixnly.  The  regular  for- 
ceps will  be  found  to  give  all  the  rotatory  force  that  it  is  safe  to  use. 
If  excessive  twisting  movement  is  to  be  applied,  use  may  be  made  of 
the  author's  forcc]-s  with  S(|uare  cannula,  into  whicli  the  stiletto,  also 
squared,  works  at  a  good  easy  fit,  yet  will  not  spring. 

For  cutting  in  two  of  pins,  wires  and  the  like,  Casselberry's  forceps. 
Fig.  o-J,  are  excellent.  Before  using,  howexer,  it  is  well  to  test  the.n 
on  a  pin  similar  to  the  one  in  the  patient,  because  if  not  correctlv  made 
thev  will  not  hold  the  fragments. 


Fig-  33-  Pointed  jaws  for  the  author's  forceps.  Useful  wlien  it  is  ilesired  to 
permit  turning  of  a  foreign  body  to  a  safer  relation  for  withdrawal,  while  securely 
held,  as  with  hones,  vulcanite  dentures,  pin-buttons,  safety-pin>,  etc.  The  points  must 
meet  point  to  point  exactly;  the  bend  must  be  acute  and  the  length  of  the  point  from 
the  bend  must  be  short — not  over  2  mm.  These  forceps  are  especially  valuable  for 
the  esophagoscopic  removal  of  open  safety-pins  by  the  author's  metliod  nf  pushiui! 
them  to  the  stomach,  turning  and  withdrawing  as  elsewhere  herein  ex]>laiued 
They  arc  called  "rotation  forceps." 


Fig.  34.     Casscll)erry's  forceps  for  endoscopic  pin  cutting.  When  correctly  made 
the  ends  of  the  [lin  are  held  by  the  forceps  so  as  not  to  be  lost. 

Briinings  uses  an  extensible  forceps  which  can  be  adjusted  fur  dif- 
ferent tube  lengths. 

Tissue  forceps.  For  the  removal  of  siiecimens  fnini  any  pari  of  the 
air  or  food  passages,  the  author's  forceps  illustrated  in  Fig.  3."),  far  sur- 
pass anything  ever  tried  by  him.  The  movable  jaw  will  take  hold  direct- 
ly on  the  side  wall,  and  there  is  no  need  of  a  side-acting  forceps.  Indeed, 
a  side-acting  forceps  will  not  work  because  it  cannot  be  pushed  sidewise 
unless  the  lateral  push  is  furnished  by  the  movement  of  tiie  endoscopic 
tube.  ^\  ith  the  forceps  illustrated  in  Fig.  o.t,  however,  a  ready  hold  is 
gotten  in  anv  kind  of  tissue  withoiu  any  lateral  movement  of  the  endos- 


l.NSTRUMKNTS. 


:?7 


copic  tube  through  whicli  tlic  fiirceps  is  passed.  'I'he  jaws  can  be  turned 
in  any  direction,  though  the  author's  own  personal  habit,  as  with  foreign 
body  forceps,  is  to  leave  the  jaws  fixed  in  the  up  and  down  direction  and 
to  get  all  movements  by  placing  the  handle,  during  the  work,  in  tlie  de- 
sired position,  leaving  the  jaws  always  in  the  same  ])osition  rclati\e  to 
the  handle.     It  is  wonderful  what  facility  can  be  de\clij|ied  by  using  this 


-yt^ 


Fig.  3$.  Autlior's  tissue  forccp.';.  The  side  jaw  will  liite  into  a  flal  lateral  wall. 
The  cross  forms  the  l)ottom  of  a  haslcet  to  hold  the  tissue  removed.  The  action  is 
very  delicate,  tliere  being  no  springs.  The  sense  of  touch  can  often  make  the  diag- 
nosis. The  best  form  for  removal  of  a  specimen  and  for  endoscopic  operations.  The 
actual  lengths  of  the  forceps  cannulae  arc  60  cm.  and  30  cm.,  respectively;  the  latter 
being  for  laryngeal  use. 


Fig.  36.  Author's  alli.ijator  punch  fnrccps  with  bar  across  both  upper  and  low- 
er rings  to  form  a  "basket "  to  hold  the  excised  fragments.  These  forceps  will  go 
thnjugh  the  author's  adult  laryngoscope,  but  he  finds  it  advantageous  to  insert  the 
forceps  alongside  the  laryngoscope,  wliicli  latter  is  only  used  to  look  through  in  the 
ocular  guidance  of  the  forceps. 

method.  (  >f  course.  diliereiU  lengths  are  re(|uircd  fur  work  in  the  larynx 
and  in  llic  esophagus,  but  clinicall\'  forceps  wUli  a  :in  cm.  cannula 
are  best  for  llic  larynx.  an<l  a  I'H  cm.  c.imuila  will  cover  all  other 
needs.  Tiiere  are  no  springs  to  opfjose  the  bite,  .uid  it  is  olten  ])i)ssiblc 
to  distinguish  the  nature  of  the  tissue  bitten  by  tlic  sensation  coiniuum- 
caled  to  the  fingers,  so  delicate  are  the  toucb  ,nid  action  of  llic  forceps. 

Sliding  ])unch  forceps  shonld  ha\c  the  upper  ring  the  smaller  one  in 
order  that  the  view  of  the  growth,  as  the  jaws  close,  shall  not  be  oii- 


38 


INSTRUMENTS. 


scured,  as  would  be  the  case  if  the  nearer  ring  were  the  larger.  Thus 
precision  may  be  assured  in  operating  or  in  the  removal  of  specimen,  as 
the  case  may  be.  The  author  has  seen  a  number  of  instruments  in  the 
shops  with  his  name  attached,  in  which  this  arrangement  of  jaws  has 
been  neglected  (Fig.  37"). 

With  a  guillotine  attached  to  the  author's  tissue  forceps,  a  project- 
ing mass  may  be  amputated  without  injury  to  the  basal  tissue  where  this 
is  deemed  desirable. 

Mouth-gag.  Wide  gagging,  as  pointed  out  by  the  author  (Bib.  3.3G), 
prevents  proper  laryngeal  exposure  and  may  thus  defeat  efiforts  at  bron- 


F'&-  37-  Correct  and  incorrect  forms  of  punch  forceps.  A,  correct  model.  The 
near  jaw  is  the  smaller.  B  and  C  incorrect  forms.  The  near  jaw  is  the  larger,  and, 
consequently,  obscures  the  view  of  the  cutting  edge.  B  has  a  swell  on  the  shank 
which  also  obscures  the  view. 


Fig.  38.  Boyce  thimble  bite  block,  to  be  used  instead  of  a  gag  to  prevent  the 
patient  biting  the  tube.  A  gag  makes  peroral  endoscopy  difficult  by  jamming  the 
mandible  down  on  the  hvoid  bone. 


choscopy  and  esophagoscopy  by  forcing  the  mandible  down  on  the  hyoid 
bone.  All  that  is  needed  in  the  way  of  a  gag  is  a  bite  block  to  prevent  the 
patient  closing  his  jaws  on  the  delicate  tube.  For  this,  Dr.  Boyce  devised 
the  thimble  bite  block  (Fig.  38)  which  has  recently  been  modified  in 
shape  by  Dr.  McKee  and  an  ether  tube  has  been  added  by  Drs.  McKee 
and  McCready  (Fig.  39).  Ether  is  insufflated  when  needed  for  esoph- 
agoscopy. In  bronchoscopy  the  insufflation  is  done  through  the  bron- 
choscope if  general  anesthesia  is  used. 


INSTRUMENTS.  39 

Stiarcs.  For  indirect  laryngoscopy  the  snare  has  the  advantage  that 
it  can  do  no  harm  as  could  the  forceps  if  misapplied.  For  direct  laryngo- 
scopy the  forceps  can  be  used  so  accurately  that  the  snare  is  rarely  use- 
ful except  for  large  tumors  of  the  larj-ngopharynx  and  the  upi)er  laryngeal 
aperture.  For  these  purposes  and  for  the  amputation  of  the  cancerous  and 
the  tuberculous  epiglottis  the  author  has  found  useful  a  \ery  heavy  snare 
cannula  (Fig.  41)  armed  with  Xo.  ">  steel  piano  wire  and  fitted  to  the 


Fig-  39-  Thimble  bite  block  (on  finger)  originally  suggested  by  Boyce  and  im- 
proved by  McKee  and  McCready.  Ether  is  insufflated  through  the  tube,  if  needed, 
for  esophagoscopy.    The  tulie  on  the  bite  block  is  not  used  in  bronchoscopy. 


.r^rrTnTtfTTIimmnil  1^:^^^=! 


Fig.  40.  Author's  mechanical  spoon  for  the  endoscopic  removal  of  soft  friable 
bodies  like  beans,  peas,  meat,  and  nut  kernels.  The  spoon-shaped  extremity  is  in- 
serted alongside  the  intruder  which  is  then  lifted  and  drawn  into  the  cud  of  the 
bronchoscope  or  esophagoscnpc-  by  the  action  of  the  s|>oon  when  the  handle  is  de- 
pressed as  shown  by  the  dotted  line. 

massive  handles  of  the  Peters  tonsil  snare.  By  firm  downward  pressure 
on  the  cannula  the  loop  can  be  made  almost  completely  to  amputate  the 
involved  epiglottis  cii  masse,  as  demonstrated  by  dis.section  of  the  re- 
moved tissues.  The  cannula  is  passed  beside  the  laryngeal  speculum,  not 
through  its  lumen.  Bronchoscopic  and  esophagoscopic  snares  are  oc- 
casionally of  service  in  solving  the  mechanical  problems  of  foreign  body 
extraction.     The   authur   on   r.irc   occasions  uses  a   verv  delicate  snare 


40 


INSTRUMENTS. 


(Fig.  -18)  made  to  work  on  a  slight  modification  of  his  universal  handle 
In  use,  the  snare  loop  is  given  a  bend  or  a  double  curve  in  one  of  many 
ways  (a  few-  of  which  are  shown  in  Fig.  42)  in  order  that  it  may  be 
placed  by  sight.  The  wire  is  easier  seen  among  the  mucus  if  it  is  not 
bright,  black  wire  giving  the  strongest  contrast.  The  end  of  the  snare 
cannula  is  so  made  that  the  loop  can  be  rotated,  and  also  so  that  the  wire 
cannot  be  draw  n  all  ibc  way  in  nor  kinked  :  therefore  the  same  wire  can 
be  iHished  or  pulled  out  and  reapplied  after  an  unsuccessful  attempt. 

1  looks  should  have  'i  cm.  of  the  proximal   end  of  their  stem  bent 
down,  cxacth    in   the  opposite  direction   from  that  of  the  hook,  to    for:n 


Fig.  41.  Heavy  snare  cannula  to  be  attached  to  the  handle  of  Peter's  tonsil 
.-nare  For  the  en  masse  removal  of  the  diseased  epiglottis  or  large  tumors  of  the 
lower  pharynx  and  upper  laryngeal  aperture.  Chondromata  and  even  the  toughest 
of  fibromata  are  readily  removed  with  this  snare.  The  snare  is  passed  alongside 
the  laryngoscope,  not  through  it. 


Fig.  42.  Bronchoscopic  snare  to  tit  the  author's  form  of  forceps  handle,  llie 
various  shapes,  shown  in  the  lower  illustration,  are  imparted  to  the  snare  loop  as 
needed  to  solve  the  mechanical  proljlem  presented  by  the  particular  case. 


a  handle  in  order  that  the  exact  direction  of  the  hooked  end  may  be 
known  to  touch  as  well  as  sight.  The  Lister  hook  and  the  half-curved 
and  full-curved  hooks  of  Killian  have  done  gOod  service.  Ingals  has  de- 
vised a  corkscrew  -hook  to  bring  a  pin  into  the  center  of  the  lumen. 

Richardson  (Bib.  4  b^  )  has  devised  an  ingenious  screw-pointed  ex- 
tractor with  which  he  removed  a  rul)l)er  pencil  eraser. 

Spectacles.  A  most  important  part  of  the  armamentarium  is  prop- 
er spectacles  specially  devised  for  the  work.  If  the  endoscopist  has  no 
refractive  error  he  will  need  two  pair  of  jilane  protective  spectacles  with 


INSTKl.-Ml'.Nl'S. 


41 


B 


Fijr.  4,!,  Cups  for  anesthetic  solutions  designed  originally  by  Vankaucr  for 
nasal  use.  Being  heavy  and  broad  based,  they  do  not  upset  readily.  The  author 
has  had  a  red  band  painted  on  one  (B)  which  is  for  20  per  cent  solution,  which  is 
used  with  great  caution. 


Fig.  44.  The  author's  endoscopic  syringe  for  injection  of  solutions  of  radium 
salts,  local  anesthetics,  and  other  medicaments.  It  is  made  in  60  cm.  length  for 
bronclioscopic  and  csophagoscopic  \\-,e,  30  cm.  for  direct  lar\ngoscopic  use.  The 
capacity  is  25  mgm.,  though  it  could  be  made  for  larger  quantities  of  solution  if 
desired. 


Fig.  45.     The  author's  small  ililiitor  lor  lirunchc  i^cupic  dilatation  of   bronchial 
strictures.  The  dilator  is  actuated  b.\  the  author's  universal  forceps  handle. 


F'ig.  46.  The  autlKrr  s  l.irgcr  dilating  forceps  with  a  channel  in  each  member. 
so  as  to  furnish  a  canal  when  the  dilator  is  closed  for  insertion.  In  use,  this  canal 
permits  the  dilator  to  be  pushed  down  over  the  presenting  point  of  such  bodies  as 
tacks.     An  enlarged  form  of  this  is  sometimes  used  for  the  larynx. 


42 


INSTRUMENTS. 


ven'  large  eyes.  If  astigmatic,  hypermetropic  or  myopic,  correction  is 
necessary  and  duplicate  spectacles  must  be  in  charge  of  a  nurse.  If 
presbyopic,  two  pair  of  spectacles  for  40  cm.  distances  and  two  pair  for 
65  cm.  distance  must  be  at  hand.  The  reason  for  duplicates  is  that  there 
is  little  or  no  loss  of  time  in  cleaning  spattered  lenses.  One  nurse  is  de- 
tailed for  spectacles  and  she  keeps  them  on  a  gauze-covered  basin  of 
warm  water  on  the  stand  of  which  hangs  a  dry  towel.  The  nurse  cleanses 
the  soiled  spectacles  and  has  them  ready  for  immediate  exchange.    Hook- 


« 


-zr  cm.  _  . 


\ 


Fig.  47.  The  author's  galvanocautery  electrode  for  endoscopic  use.  It  is  es- 
pecially adapted  to  cauterization  of  subglottic  edema,  and  subglottic  hyperplasia 
such  as  follows  diphtheria.  As  with  the  author's  pointed  electrode  (Bib.  269)  the 
hard  rubber  is  vulcanized  onto  the  conducting  wires,  assuring  cleanliness.  Thread 
wound  electrodes  become  filthy  with  blood  and  secretions. 


ESijta 


Fig.  48.     Mosher's  esophageal  dilator.     B.    Actual  size  of  distal  end. 


=^<S>e 


Fig.  49- 
vcrtebrated. 


I'luminer's  double  olive  bougie.     The  stem  between  the  two  olives  is 


temple  frames  should  be  used.  Eye-glasses  are  objectionable  because 
they  are  not  so  quickly  placed  by  the  nurse  when  exchanging,  and  also 
because  they  are  very  apt  to  become  displaced  while  working.  Of  course, 
the  operator  cannot  handle  them  after  he  has  sterilized  his  hands. 

Endoscopic  table.     In  an  emergency  any  sort  of  table  can  be  used, 
but  where  a  special  table  is  to  be  provided,  the  best  one  to  be  obtained  is 


INSTRUMENTS. 


4;? 


that  of  Dr.  T.  R.  French  (Fig.  54)  designed  especially  for  nasal  and 
throat  operations.  The  ease  with  which  a  trained  assistant  can  raise  or 
lower,  or  change  the  angle  of  inclination  of  the  patient  is  a  great  con- 
venience. The  shortening  and  lengthening  of  the  head-end  of  the  table 
enables  the  operator  to  have  any  desired  degree  of  overhang  of  the  shoul- 
ders. All  of  these  movements  are  under  perfect  control  of  the  wheels 
manipulated  by  the  second  assistant.  The  table  should  be  covered  with 
a  good  pad  against  which  a  child  can  be  held  firmly  without  discomfort. 
Oj^erating  room.  All  peroral  endoscopy,  except  the  diagnostic  ex- 
aminations of  children   suspected   of  diphtheria,   should  be  done   in   an 


Fig.  50.  Author's  eyed  bougie  for  esophagoscopic  threading  over  a  swallowed 
braided  silk  string.  Twelve  bougies  with  successive  sizes  of  olives  are  made.  The 
pro.ximal  end  of  the  string  is  threaded  through  the  esophagoscope.  The  esophago- 
scope  is  passed ;  then  the  bougie  is  threaded  and  passed  along  the  thread  which  is 
held  taut. 


Fig.  51.  Upper  illustration.  Author's  eycd-probe  for  endoscopic  use.  Lower 
illustration.  Author's  string-cutting  esophagotome.  The  braided  silk  cord  works 
in  a  protecting  groove  on  one  side  of  the  olive,  the  cutting  being  done  on  the  other 
side  which  is  turned  toward  the  cicatrix  when  the  latter  is  not  annular. 


operating  room.  A  room  which  can  be  darkened  is  a  necessity  for  en- 
doscopy. Absolute  darkness  is  of  course  not  necessary  nor  desirable. 
There  should  be  enough  illumination,  of  a  feeble  kind,  to  permit  the 
nurses  and  assistants  to  find  wdiat  is  needed  on  the  sterile  table.  It  is 
quite  necessary  that  whatever  windows  there  are  should  be  at  the  back 
of  the  operator,  because  a  little  streak  of  light  leaking  in  past  blinds  and 
shining  directly  into  the  eye  of  the  operator,  is  partictilarlv  annoying  and 
an  inconvenience.     The  expert  operator  will  get  along  with  quite  a  bright 


a  IXS'I'KUMI'.XTS. 

light  in  the  ronni.  but  when  it  comes  to  intricate  and  difficult  work,  it  is 
necessary  to  have  a  darkened  room.  All  endoscopy  should  be  done  with 
both  of  the  endoscopist's  eyes  o]jen.  Prolonged  work  with  the  left  evelid 
closed  is  very  fatiguing,  and  interferes  with  \ision  of  the  right.  Ignoring 
of  the  image  of  the  open  left  eye  is  facilitated  by  a  darkened  room. 

Operating   room   orqanicatioi.     Once  an   endoscopic   procedure   has 
been  starteil,  moments  are  exceedingly  precious.   For  this  reason,  every  de- 


CLOSED 


OPEN 

Fig.  $2.  .\uthor's  dilator  for  endoscopic  use  in  lironchial  and  esophageal  stric- 
tures. Invaluable  in  dilating  successively  each  of  a  series  of  strictures,  especially 
when  the  lumina  of  the  lower  ones  are  eccentric  to  those  above,  because  it  does 
not  need  to  be  inserted  far. 


,c 60-cm- 


B 
< -lo-cm^ > 

Fig.  53.  Filiform  bougie  for  minute  cicatricial  strictures  of  the  esophagus. 
The  filiform  silk  woven  end,  A,  is  joined  securely  to  a  spring  steel  shaft,  B,  thus 
giving  all  the  advantages  in  safety  of  a  silk  woven  bougie  at  the  tip  with  a  stiflf 
shank  that  enables  the  bougie  to  be  carried  down  rigidly  through  the  length  of  the 
esophagoscope.  Twelve  sizes  are  made.  The  total  length  of  60  cm,  is  only  neces- 
sary in  case  of  a  very  low  stricture  in  an  adult.  For  use  in  children,  the  bougie 
ran  be  shortened  by  unscrewing.  The  great  advantage  of  the  steel  shaft  over  any 
sort  01  stylet  inserted  into  a  hollow  filiform  is  that  the  small  diameter  of  the  steel 
shank  permits  of  more  accurate  ocular  guidance.  These  bougies  are  modeled  after 
those  of  Guisez. 

tail  must  be  carried  out  including  c\ery  instrument  that  would  e\er  be 
wanted.  Instruments  not  likely  to  be  needed  are  kept  sterile  on  a  se[)arate 
table,  so  that  the  working  table  will  not  be  encumbered  by  anything  but 
the  regular  working-set  of  instruments.  The  tubes  are  all  kept  with  tin; 
batteries  in  the  manner  shown  in  Fig.  5."),  so  that  the  surplus  tubes  not 
in  use  will  in  no  way  interfere  with  the  quick  handling  of  forceps  and 
sjionge  carriers.  The  arrangement  of  the  instrument  table,  the  assistants, 
the  batterv,  instrument  nurse  and  anesthetist,  as  shown  on   page   4i)   in 


IXSTRUMKNTS. 


45 


the  earlier  volume,  lias  lieeii  [)roven  to  be  invaluable  in  expetliting  care- 
ful work.  The  great  advantage  of  having  these  regular  positions  is  the 
avoidance  of  confusion.  Anything  needed  is  always  in  precisely  the 
.■^ame  location.  The  author  has  been  able  by  this  means  to  do  just  as 
good  work  in  one  hospital  as  in  another  by  taking  an  assistant  and  a 
nurse  with  him.  This,  however,  is  not  meant  to  say  how  good  or  how 
bad  the  work  may  have  been,  but  such  as  it  was,  it  represented  the  liest 
that  the  author  could  do  under  any  circumstances. 

O.vyc/ni  tank  and  tracheotomy  instruments.  In  all  instances,  as  a 
matter  of  routine,  instruments  for  traclieotomy  should  be  on  the  sterile 
table  read\-  for  immediate  use  in  every  case  of  bronchoscopy  or  esoph- 
agosco[)y.  or   direct   l;>ryni,mscopy.      It   is  exceedingly    rarely,    rclatixcly, 


Fig.  54.  Dr.  T.  K.  Frenfli  operating  talilc.  All  positions  are  readily  obtained 
by  tbc  three  control  wheels.  The  bead  board  can  be  extended  or  shortened  to  bring 
the  shonlders  of  the  patient  to  the  best  position. 


that  they  will  lie  reipiired,  but  when  nee(le<l,  ihey  should  be  immediately 
at  hand,  sterile  and  ready.  Ily  having  these  preparations  always  part  of 
the  sterile  table  sellings,  a  few  lives  can  be  saved  that  ollierwise  would 
be  lost  by  the  delay  or  by  sepsis.  An  ox\gen  lank  in  a  roller  stand 
(Fig.  .")(>)  is  most  manageable.  It  shotild  be  covered  with  sterile  towels 
pinned  on,  over  valve-wheel  and  all,  and  a  length  of  sterilized  rubber  tub- 
ing should  be  connected.  I  f  this  lank  should  be  prepared  only  in  such 
cases  as  may  seem  beforehand  likely  to  need  it,  the  surgeon  will  find,  to 
his  chagrin,  that  when  most  wanted  it  will  not  be  at  hand.  It  is  just 
such  little  details  that  make  the  dift'erence  between  high  ami  Idw  morlal- 
itv  in  anv  siu'gical  procedtire.  In  rcspir.itory  arrest  from  the  pressure 
of  the  esoi)hagoseope  or  of  the  foreign  body,  lumor,  diverliculnm  full  of 
food,  resi)iralii)n  will  not  be  started  again  unless  a  bronchosct)pe  be  in- 


4G  INSTRUMENTS. 

troduced  into  the  tracliea  or  a  tracheotomy  be  done  for  oxygen  and  amyl 
nitrite  insufflation.  Amyl  nitrite  should  always  be  at  hand  in  the  torm 
of  capsules. 

Head  cozier.  The  author  uses  a  head  cover  for  the  patient,  which 
is  simply  a  muslin  bag  large  enough  to  go  down  to  the  shoulders.  A 
round  hole  about  four  inches  in  diameter  is  cut  at  the  level  of  the  mouth. 
This  cap  enables  the  operator  and  the  second  assistant  to  hold  the  head 
without  infecting  their  hands.  It  involves  a  grave  risk  to  handle  instru- 
ments that  go  into  the  lung  after  handling  a  patient's  head. 

Asepsis.  The  author's  early  insistence  (Bib.  2(39)  upon  strictly 
aseptic  operating-room  technic  in  all  forms  of  peroral  endoscopy,  w'hile 
much  ridiculed  at  the  time,  has  come  to  be  recognized  everywhere  as  quite 
essential  in  a  procedure  which  necessarily  fre(|uently  comes  in  contact 
with  tuberculosis,  pneumonia,  diphtheria,  erysipelas,  lues  and  other  in- 
fectious diseases  and  pyogenic  infections.  It  is  a  matter  of  great  grat- 
ification to  the  author  that  in  fifty  examinations  of  swabs  used  for  wiping 
secretions  from  the  bronchi,  in  no  instance  was  there  found  any  trace 
of  such  epithelial  cells  or  of  such  forms  of  bacteria  as  would  prove  that 
the  instruments  had  been  in  any  way  contaminated  by  contact  with  the 
mouth.  This  is  worthy  of  note  in  connection  with  the  obtaining  of 
inoculation  material  for  the  production  of  autogenous  vaccines  in  cases 
of  chronic  bronchitis,  etc. 

As  before  pointed  out  (Bib.  2(i9),  it  is  necessary  to  remember  that 
though  the  field  cannot  be  sterilized,  yet  the  patient  is  more  or  less  im- 
mune to  the  organisms  that  he,  himself,  harbors,  while  he  may  be  ex- 
tremely susceptible  to  organisms  introduced  from  another  source,  even 
though  such  newly-introduced  organisms  mav  be  morphologically  the 
same.  Bacteria  from  the  patient's  own  skin  and  hair  come  under  the 
class  of  foreign  organisms  wdien  introduced  into  the  lungs  or  into  the 
blood  and  lymph  channels  in  operative  work.  The  only  way  to  be  cer- 
tain of  avoiding  the  introduction  of  ])athogenic  organisms  from  a  previ- 
ous patient,  or  from  any  other  source,  is  to  carry  out  all  the  details  of 
aseptic  operative  technic.  Then  if  a  patient  gets  pnemnonia  or  any  other 
infection  the  operator  has  all  the  comfort  of  a  clear  conscience.  A  mask 
should  always  be  worn  by  the  operator  to  protect  both  the  patient  and 
himself  from  infections  that  either  may  unknowingly  have.  It  is  not 
pleasant  to  have  even  uninfective  secretions  coughed  in  one's  face.  Large 
plane  protective  spectacles  should  be  worn  over  the  o])erator's  eyes  it 
he  does  not  rccjnire  corrective  lenses.  The  patient  should  be  covered 
with  a  sterile  gown,  and  a  cap  coming  down  to  the  shoulders  with  a 
hole  in  it  corresponding  in  position  to  the  mouth,  but  larger:  about  ID 
cm.  in  diameter.     Assistants,  even  the  one  who  holds  the  head,  and  also 


INSTRUMKNTS.  4? 

the  anesthetist,  if  one  is  needed,  should  put  their  hands  through  the  same 
process  of  sterihzation  as  for  any  surgical  operation.  All  of  the  sterile 
team  should  wear  sterile  caps.  Instruments  should  be  sterilized  by  boil- 
ing, except  the  lamps,  light  carriers,  knives  and  scissors.  These  should 
be  immersed  in  alcohol.  Extra  lamps  should  be  sterilized  so  as  to  be 
ready  if  needed.  Conducting  cords  may  he  wiped  with  alcohol,  but  it 
must  be  strong  alcohol,  because  alcohol  diluted  with  water  may  tem- 
porarily impair  insulation.  Conducting  cords  should  be  covered  with 
close-fitting  rubber  tubing  for  cleanliness. 

LIST  OF   INSTRU.MliXTS. 

The  following  list,  given  as  a  convenient  basis  for  equipment,  has 
been  listed  from  the  author's  armamentarium.  The  essentials  for  ordi- 
nary work  are  marked  with  an  asterisk.  Bougies,  dilators  and  the  like 
are  not  so  marked  because  they  are  not  emergency  instruments ;  though 
they  are  essential  to  the  endoscopist  who  expects  to  deal  with  all  kinds  of 
cases.  Special  instruments  may  need  to  be  devised  for  special 
cases.  The  instruments  listed,  unless  names  are  mentioned,  are  of  the 
author's  design.  These  might  not  suit  others,  and  it  is  better  for  the  en- 
doscopist personally  to  examine  and  select  instruments  that  appeal  to 
him  personally. 
Tubes: 

*1    direct  laryngoscope   for  children. 

*1    direct  laryngoscope  for  adults. 

*1  bronchoscope,   I  mm.  x  '.W  cm.,  for  children. 

*1    bronchoscope,  'i  mm.  x  ;50  cm.,  for  children. 

*1    bronchoscope.  7  mm.  x  10  cm.,  for  adults  and  older  children. 

*1    bronchoscope,  !•  mm.  x  40  cm.,  for  adults. 
1    esophageal  speculimi  for  cliildren. 
1  esophageal  speculum  for  adults. 

*]    esophagoscope,  7  mm.  .x  -J-")  cin.,  fur  ibildren.     (  Slanted  end.  ) 
1   esophagosco])e,  fi  mm.  x  \'>  cm.,  for  older  children. 

*1   esophagoscope,  10  mm.  x  'i'-i  cm.,  for  adults.     (Slanted  end.) 
Extra  lamps.    (At  least  1  dozen.) 
Accessories : 

*1     bite  block.  McCready-McKee. 

*l    Sajous  laryngeal  cotton  forceps,  long,  full,  curved. 

*1   as])irator  and  tubing  for  both  i)ositivc  and  negative  pressure. 

*ls  sponge  holders  with  long  screw  collar. 

*1    force])S,  plain  foreign  body  jaws  with  handle    I")  cm.  and  (>0  cm. 
1   forceps,  side  curved,  with  handle  4.')  cm.  and  (>0  cm. 


48  INSTIU'.MlCKTS. 

I    t'orce])s,  with  r()tati<in  jaws  with  liandle,   1-")  cm.  and  (io  cm. 

1  Ca.sselheiiy'.s  pin-cutting  forceps. 
*1  laryngeal  tissue   forceps  with  basket  tip. 
*1   Moshcr  alligator  forceps. 

1  jninch  forceps  with  roimd  and  triangular  jaws. 

1  guillotine  forceps. 
*1  mechanical  spoon. 

1  bronchoscopic  snare. 

1  esophagoscopic  snare. 

1  Lister  hook. 
*1   full-cur\ed  hook. 

1  half-curved  hook. 

2  bronchoscopic  dilators,  large  and  small. 

1  safety-pin  closer. 

*1  steel  measuring  rule,  2(1  cm.  long. 

2  cautery  electrodes  and  cord. 
1    Ijcnt  hook  mouth-aspirator. 

]    laryngeal  dilator,  parallel  blades. 

1  Mosher's  esophageal  dilator  for  cardia. 
Bougies  metal  with  silk-woven  ends, 
liougies,  double  olive. 

I'orcelain  cups  for  local  anesthesia  scilutions,  1  with  reel  ban<l. 
*Sponges,  a  .good  suppK-  would  be  abnut  1  dozen  of  each  size. 

■i  extra  battery  cords. 
*2  dry  cell  batteries  with  two  circuits  each. 

2  battery  covers. 

1   face  cap  for  patient. 

Tracheotomy  instruinents. 

Extra  spectacles  with  large  lenses  to  protect  ojierator's  eyes. 
Care  of  instnniioils.  Next  in  importance  to  ha\ing  a  well-made 
and  carefully  selected  instrumental  eijuipment,  is  the  keei)ing  of  the 
equipment  in  proper  order.  iMir  this  pur[)ose  the  endoscojVist  should  have 
an  instrument  nurse  in  his  own  employ,  or  he  should  look  after  the  care 
himself,  for,  imfortunately,  the  constantl\-  changing  working-force  in  the 
usual  operating  room  results  in  the  instruments  falling  into  the  hands  of 
a  new  nurse  at  freeinent  intervals,  and  alas  too  often  a  pupil-nin\se,  who, 
however  competent  to  scrub  and  [lolish  the  instruments  of  the  general 
surgeon,  will  work  sad  havoc  with  the  endoscopist's  equipment;  and  con- 
sequentU-  the  next  time  a  bronchoscopy  is  in  order  the  endoscopist  will 
find  his  work  dilticult  or  impossible  because  of  forceps  bent  or  corroded, 
small  parts  lost,  tubes  dinged,  canals  choked  with  blood  or  secretions, 
adherent  to  the  inner  walls  and  coagulated  by  boiling.     The  sooner  the 


INSTRUMENTS. 


49 


endoscopist  realizes  that  he  is  simply  a  mechanic  ami  that  to  do  good 
work  a  mechanic  must  have  good  tools  kept  in  proper  order,  the  better 
his  results  will  be.  Otherwise,  he  will  never  obtain  the  high  percentage 
of  successes  of  the  good  mechanic  who  keeps  his  tools  in  good  order. 
To  keep  instruments  in  the  proper  condition  recpiires  not  oidy  good  care 
but  very  frc(|uent  careful  inspection,  for  the  fre(|uent  cleansings.  tiie  tak- 
ing apart  and  putting  together,  the  boiling  as  well  as  the  actual  use  of 
the  instruments,  result  in  deterioration.  Tiiis  applies  especially  to  for- 
ceps, which  ha\e  the  heaviest  work  to  do,  and  which  must  necessarily  be 
delicate  in  construction.     The  jaws  at  the  end  of  all  forms  of  tube  for- 


Fig.  55.  Manner  of  arranging  sterile  instruments  and  batteries.  Tlie  battery 
lids  are  opened  back  outward  in  opposite  directions,  tben  each  is  covered  witb  a 
special  sterile  cover.  The  crevice  Ijetween  is  used  to  bold  tubes  wbich  are  readily 
identitied  liy  tlieir  distal  ends  which  are  always  uppermost.  Laryngoscopes  are  in 
the  battery  lids. 


ceps  arc  necessarily  tcnii)ered  to  a  s[)ring  temper.  If  the  temper  is  a  lit- 
tle too  high,  nr  if  slight  corrosion  has  taken  jilace.  the  forceps  are  very 
apt  to  break.  'J'his  is  an  exceedingly  embarrassing  accident  resulting  not 
only  in  the  loss  of  the  foreign  body,  but  in  the  introduction  of  a  fresh 
foreign  body  in  the  form  of  a  lost  part  of  the  instrument.  Consequently 
after  much  use  it  is  wise  to  throw  away  the  stylet  jaws  of  tube  forceps 
and  replace  them  with  new  ones.  This,  with  careful  inspection  before 
each  operation,  will  ])revent  accidents  and  failures.  After  operation  tlie 
canal  for  the  light  carrier,  and  in  the  case  of  the  esophagoscoiie.  the  drain- 
age canal,  should  be  cleaned  first,  by  forcing  cold  water  through  the  canal 
with  the  aspirating  syringe,  and  then  by  pushing  through  a  long  cotton 


50 


TNSTRUMKNTS. 


brush  formed  on  wire,  such  as  used  for  cleaning  the  canal  in  the  stem  of 
a  tobacco  pipe.  As  usually  sold  in  the  tobacco  shops  it  is  cut  in  short 
lengths,  but  it  can  be  obtained  from  the  factory  in  coils.  It  is  stiflf  enough 
to  be  pushed  through  the  canals,  provided  the  canals  are  always  cleaned 
immediately  after  operation  and  the  secretions  not  permitted  to  stick  in 
the  canal,  either  by  coagulation  or  by  boiling.  Forceps  should  be  taken 
apart  and  the  cannula  cleaned  thoroughly  by  running  cold  water  through 
it.  The  stilette  should  be  cleaned  and  then  polished  with  a  bit  of  emerj- 
paper  and  carefully  oiled  before  replacing  it  in  the  cannula.  If  the  can- 
nulae  of  forceps  are  made   of  spring-tempered   brass   tubing,   they   are 


Fig.  56.  Ox)'gen  tank-  stand.  Very  light  and  convenient  to  go  under  the  head 
of  the  operating  table  when  needed  so  as  to  be  out  of  the  way  during  bronchoscopic 
oxygen  insufflation. 


much  less  subject  to  corrosion  than  steel  is  to  rust.  It  is  necessary  to  see 
that  the  sliding  edges  of  the  direct  laryngoscope  are  not  injured  and  that 
the  slide  works  freely  and  comes  away  readily,  unless  as  is  now  done  by 
many  the  oval  laryngoscope  is  used  without  the  slide.  Roughness  of 
tubes  is  readily  detected  by  passing  the  finger  all  over  them.  The  distal 
ends  are  particularly  prone  to  get  little  rough  places.  Rubbing  with  the 
smoothest  quality  of  emery  paper  will  remove  roughness.  Some  of  the 
plating  may  be  thus  removed,  but  the  author  prefers  instruments  not  plat- 
ed anyway,  for  jjlating  is  apt  to  scale  off.  To  keep  in  order  batteries  of 
the  form  used  by  the  author,  it  is  only  necessary  to  renew  the  dry  cells 


INSTRUMENTS.  31 

once  every  three  or  four  months,  whether  used  or  not.  If  care  is  taken 
to  see  that  all  connections  are  screwed  up  tightly,  no  one  should  ever  fail 
for  want  of  current.  Before  sterilizing,  the  cords  and  lamps  should  be 
tested,  the  lamps  being  allowed  to  remain  in  the  light  carriers  which 
are  then  immersed  in  alcohol. 

In  over  three  thousand  endoscopies  neither  Dr.  Patterson  nor  the 
author  has  ever  failed  for  want  of  a  light.  This  has  not  been  a  matter 
of  luck ;  but  rather  a  little  attention  to  see  that  everything  is  right  before 
starting,  and  the  observance  of  a  rule  always  to  have  a  duplicate  in  re- 
serve, precisely  as  is  done  in  all  commercial  lighting  installations  or  in 
the  "dual  ignition"  systems  of  modern  internal  combustion  motors.  This 
is  not  boasting.  It  is  too  trivial  a  matter.  In  fact  the  matter  is  so  very 
trivial  that  few  operators  will  give  the  electric  details  any  attention. 
There  is  no  mystery  about  electric  trouble ;  and  he  who  is  master  of  his 
instrument  and  its  few  and  simple  details  will  always  have  satisfactory 
light.  \'iolin  strings  are  prone  to  break;  but  this  does  not  cancel  the  vir- 
tuoso's concert  nor  make  him  resort  to  wire  strings. 


CHAPTER     II. 

Anatomy. 

Anatomical  knowledge  of  the  kind  rec|uired  for  bronchoscopy  and 
esophagoscopy  cannot  be  obtained  from  a  book.  The  anatomy  of  the 
tracheo-bronchial  tree  and  of  the  esophagus  was  considered  in  the  au- 
thor's earlier  work.  In  addition  to  the  notes  there  given  the  broncho- 
esophagoscopist  is  advised  to  study  the  anatomy  as  given  in  the  standard 
anatomical  works  and  then  to  pass  the  bronchoscope  and  the  esophago- 
scope  repeatedly  on  the  cadaver  with  the  thorax  opened  to  full  view  in 
order  to  get  in  mind  the  precise  relations  of  the  various  surrounding 
viscera.  As  the  identification  of  landmarks  is  very  much  easier  on  the 
cadaver  because  of  the  stillness  and  the  absence  of  renewal  of  secretions 
once  they  are  removed,  the  bronchoscopist  should  practice  the  identifica- 
tion of  the  bifurcation  and  of  the  orifices  of  the  upper,  middle  and  the 
lower  lobe  bronchi  on  the  right  side,  and  of  the  upper  and  lower  lobe 
bronchi  on  the  left  side.  \'ariations  of  the  endoscopic  appearances  in  the 
tracheo-bronchial  tree  and  in  the  esophagus  were  considered  in  the  earlier 
work  and  will  be  alluded  to  still  further  when  writing  of  the  introduc- 
tion of  the  bronchoscope  and  of  the  esophagoscope.  The  articles  of  In- 
gals.  ]jrown-l\elly,  Mosher,  and  particularly  the  interesting  article  of 
LieliauU  (  Bib.  :y29  )  and  the  verv  elaliorate  paper  by  iMchnert  (Bib.  404  I 
are  well  worthy  of  careful  study.  The  latter  authority  distinguishes  thir- 
teen physiological  constrictions  in  the  esophagus.  For  endoscopic  pur- 
poses only  four  of  these  need  be  considered,  namely,  the  cricoidal,  the 
aortal,  the  bronchial,  and  the  hiatal.  To  these  some  authors  would  add 
the  cardia.  Consideration  of  the  endoscopic  appearances  of  the  four  con- 
strictions mentioned  will  be  alluded  to  in  connection  with  the  introduction 
of  the  esophagoscope.  The  endoscopic  anatomy  of  the  larynx  will  be 
studied  from  the  new  direct  view-point  under  the  heading  of  direct  laryn- 
goscopy and  elsewhere.  'J'he  illustrations  and  even  the  lan,-ngeal  image  of 
the  indirect  method  are  C|uite  misleading,  and  we  cannot  obtain  true  di- 
rect image  simjily  by  inverting  a  drawing  of  the  indirect  image. 


CHAPTER     III. 

Preparation  of  the  Patient  for  Peroral  Endoscopy. 

The  suggestions  of  the  author  in  the  earHer  \-olunie  in  regard  t(j  pre- 
paration of  the  patient,  as  for  any  operation  l)v  a  Lath,  laxative,  etc.,  and 
especially  by  special  cleansing  of  the  mouth  with  'i'>  per  cent  alcohol 
have  received  general  endorsement,  .\rliticial  dentures  should  be  re- 
moved. Even  if  no  anesthetic  is  to  be  used,  the  patient  should  he  fasted 
for  five  hours  if  possible,  even  for  direct  laryngoscop)'  in  order  to  fore- 
stall vomiting.  Except  in  emergency  cases  every  patient  should  be  gone 
over  by  an  internist  for  organic  disease  in  any  form.  I  f  an  endolaryn- 
geal  operation  is  needed  by  a  nej^hritic,  preparatory  treatment  may  pre- 
vent laryngeal  edema  or  (jther  complications.  Hemophilia  should  be 
thought  of.  It  is  (|uite  common  for  the  first  symptom  of  an  aortic 
aneurysm  to  be  an  imjiaired  ]w\ver  to  swallow  or  the  lodgment  of  a 
bolus  of  meat  or  other  foreign  body.  If  aneurysm  is  present  and  esoph- 
agoscopy  is  necessary,  as  it  always  is  in  foreign  body  cases,  "to  be 
forewarned  is  to  be  forearmed."  I'ulmonary  tuberculosis  is  often  un- 
suspected in  very  young  children.  'I'liere  is  great  danger  from  tracheal 
pressure  by  an  esophageal  dixerticiiluni  or  dilatation  distended  with 
food  :  or  the  food  may  be  regurgitated  and  aspirated  into  the  larynx 
and  trachea.  Therefore,  in  all  eso])liageal  cases  the  eso])hagus  shottld 
be  eniptieil  by  regurgitation  induced  bv  titillating  the  fauces  with  the 
finger  alter  swalkiwing  a  tumblerful  of  water,  pressure  on  the  neck,  etc. 
.Aspiration  will  succeed  in  some  cases.  In  others  it  is  absolutely  neces- 
sary to  remo\e  the  fnod  with  the  esophagoscope.  If  the  aspirating  tube 
becomes  clogged  b}'  solid  food,  the  method  of  swab  aspiration  mentioned 
under  bronchoscopy  will  succeed.  ( )f  course  there  is  usualU'  no  cough 
to  aid,  but  the  iii\iphiiit;u"\  ;iliilominal  and  thoracic  compression  helps. 
Should  a  patient  arrive  in  a  serious  state  of  water-hunger,  as  explained 
under  "t'onlraindicalions  to  Esoijhagoscojjy,"  the  patient  must  be  given 
w.'iter  by  hy])(j(lermoclysis  and  enteroclysis,  as  ]iart  of  the  preparation 
and  if  necessary  the  endoscopy,  except  in  dyspneic  cases,  must  be  de- 
layed until  the  danger  of  water-starvation  is  jiast. 

Every  patient  should  be  exannned  by  indirect,  nnrior  laryngo>cop\ 
as  a  prelimin;iry  to  peroral  endoscojjy  for  any  jjurpose  whatsoever  ;  and 
it  becomes  doubly  necessary  in  cases  that  are  to  be  anesthetized  as  ex- 
l)lained  in  the  beginning  of  the  chapter  on  direct  laryngoscopy. 


CHAPTER     IV. 

Anesthesia  for  Peroral  Endoscopy. 

While  it  is  impossible  to  lay  down  any  hard  and  fast  rules  for  anes- 
thesia in  tube  work,  yet  the  time  has  arrived  when  we  may  formulate 
a  few  general  principles  from  which  deviation  can  be  made  to  suit  the 
particular  case  or  the  operator's  personal  equation.  The  herein  given 
rules  were  submitted  by  the  author  for  discussion  at  a  meeting  of  the 
American  Laryngological  Association.* 

In  the  very  interesting  and  extensive  discussion  which  followed, 
the  conclusions  were  endorsed  in  the  main.  Particular  emphasis  was 
placed  upon  the  statement  that  the  personal  equation  of  the  operator  and 
of  the  particular  case  should  govern  the  question  as  to  whether  general, 
local,  or  no  anesthetic  at  all  is  to  be  used. 

Total  abolition  of  the  cough-reflex  should  only  be  for  short  periods. 
The  facile  operator  will  do  good  work  in  many  cases  in  spite  of  a  mod- 
erate degree  of  cough.  After  a  short  period  of  tubal  contact  in  bronchos- 
copy, coughing  lessens  and  often  practically  ceases,  especially  in  infants. 
Following  the  general  rule  in  surgery,  an  anesthetic  should  never  be  used 
at  all  unless  necessary ;  never  in  greater  quantity  than  the  needed  mini- 
mum. In  general  surgery,  anesthesia  is  required  for  three  purposes : 
(1)  The  obtunding  of  pain  (reallv  analgesia)  ;  (3)  the  abolition  of  re- 
flexes (relaxation),  and  (3)  for  psychic  efTect  (mainly  abolition  of  ap- 
prehension). For  peroral  endoscopy,  analgesia  is  not  required,  for  the 
pain  in  careful  work  is  exceedingly  slight ;  but  anesthesia  for  the  lessen- 
ing of  the  reflexes  and  for  the  lessening  of  the  apprehension  which  in- 
tensifies the  reflexes,  is  necessary  under  certain  circumstances.  These 
reflexes  are  manifested  by  spasmodic  action  of  certain  muscular  systems, 
chiefly  those  of  vomiturition  and  coughing.  In  so  far  as  these  may  be 
excited  by  mucosal  contact  they  may  be  controlled  by  local  anesthesia 
alone ;  for,  of  course,  local  anesthesia  is  purely  and  simply  mucosal  anes- 

•Proceedingrs  Amer.   Laryng:ol.  .\ssociation.  Ill  12.   p.  gs. 


ANESTHESIA  I"()!<  PERORAL  ENDOSCOPY.  55 

thesia.  Muscular  contractions,  as  well  as  pain,  resulting  from  psychic 
mechanism,  or  traction  upon  tissues  remote  from  the  mucosa  can  only 
be  controlled  by  deep  general  anesthesia,  or  to  a  less  degree,  by  the  con- 
trol of  the  patient's  mental  state  by  the  personality  of  the  operator.  The 
degree  of  this  control  varies  widely  with  the  personal  equation  of  the 
operator  as  well  as  of  the  patient.  The  operator  who  can  keep  his  pa- 
tient free  from  apprehension  and  who  can  keep  his  patient's  mind  fixed 
on  the  task  of  breathing  slowly,  deeply,  and  regularly  will  get  along 
without  any  anesthetic  and  do  better  work  than  another  operator  under 
profound  general  anesthesia.  As  Briinings  has  pointed  out,  the  operator 
who  is  not  sufficiently  practiced  to  pass  the  tubes  without  general  anes- 
thesia is  not  justified  in  using  general  anesthesia  to  overcome  faults  in 
technic. 

.Incstlit'sia  for  esophagoscopy.  1.  For  foreign  bodies,  no  anes- 
thetic is  needed  in  either  adults  or  children,  except  in  case  of  very  large 
and  shaqj  foreign  bodies,  wherein  the  relaxation  of  the  esophageal  mus- 
culature, by  deep  general  anesthesia,  will  obviate  the  trauma  incident  to 
the  withdrawal  of  the  intruder  through  a  spasmodically  constricted 
lumen. 

2.  In  case  of  a  sharp  foreign  liody  threatening  perforation,  espe- 
cially open  safety-pins,  it  is  safer  to  abolish  antiperistalsis  by  deep  gen- 
eral anesthesia. 

.'!.  In  cases  of  suspected  esophagismus  and  "cardiospasm,"  the  spas- 
modic element  can  be  entirely  eliminated  by  deep  general  anesthesia. 

4.  In  case  of  large  foreign  bodies,  general  anesthesia  adds  enor- 
mously to  the  danger  of  respiratory  arrest  from  pressure  of  the  foreign 
body  on  the  trachea  and  on  the  peripheral  nervous  respiratory  mechanism. 

5.  The  use  of  a  general  anesthetic  will  greatly  lessen  the  need  for 
skill  in  the  introduction  of  the  esophagoscope ;  but  such  use  is  utterly  un- 
justifiable. 

(i.  Local  anesthesia  is  needless  for  esophagoscopy.  If  used  at  all, 
it  should  be  applied  only  to  the  laryngo-pharynx,  never  to  the  esophagus. 

.hnstliesia  for  direct  laryngoscopy.  1.  For  diagnosis.  In  infants 
and  children,  no  anesthetic  whatever  in  any  case.  In  adults  who  tolerate 
indirect  laryngoscopy  well,  no  anesthetic,  general  or  local,  is  needed. 

2.  Foreign  bodies.  In  infants  and  children,  no  anesthesia,  general 
or  local. 

.'i.  P'or  the  removal  of  foreign  bodies  fnjm  the  larynx,  both  local 
and  general  anesthesia  should  be  avoided,  lest  their  application  lead  to 
dislodgment  of  the  intruder. 

4.  For  papillomata  in  children,  no  anesthetic,  general  or  local,  is 
needed.  In  adults,  local  anesthesia  is  usually  necessary  for  accurate 
work  in  removing  specimens  or  entire  neo[)lasnis  of  any  kind. 


56  ANESTHESIA  FOR  PEKORAL  ENDOSCUl'V. 

•J.  In  a  few  adults,  intolerant  and  uncontrollable  general  excitability, 
and  in  some  cases  of  hysteria  a  general  anesthetic  may  be  necessary  for 
accurate  work  in  the  removal  of  laryngeal  neoplasms  ;  but  such  cases  are 
exceedingly   rare. 

Oral  bronchoscopy.  1.  For  diagnosis,  in  children,  no  anesthesia, 
general  or  local :  in  adults,  local  anesthesia  of  the  trachea  and  bronchi,  as 
well  as  of  the  larynx  will  be  needed. 

2.  For  foreign  bodies  in  the  trachea  anil  bronchi  of  infants  and 
small  children  no  anesthetic,  general  or  local,  is  needed,  except  possibly 
in  very  complicated  removals,  such  as  in  case  of  open  safety-pins.  For- 
eign bodies  in  the  trachea  and  bronchi  of  adults  can  often  be  removed 
without  any  anesthesia,  general  or  local ;  but  in  most  cases  local  anes- 
thesia is  needed.  General  anesthesia  is  needed  only  in  complicated  cases 
where  there  is  a  stricture  to  dilate  to  reach  the  foreign  body,  or  w'here 
the  mechanical  problem  of  removal  is  complex,  or  where  the  cough 
threatens  to  cause  perforation. 

:'.  For  the  after-treatment  of  stricture  local  anesthesia  is  sufficient, 
and  in  some  cases  none  is  needed,  because  tolerance  to  manipulation  be- 
comes established  after  repeated  passage  of  the  instruments. 

Trachcotomic  bronchoscopy.  If  lower  bronchoscopy  is  ever  justi- 
fiable, it  is  only  so  in  cases  with  extremely  severe  dys])nea,  and  even  in 
such  cases  the  facile  operator  will  slip  in  a  bronchoscope,  through  which, 
with  the  aid  of  amyl  nitrite  and  oxygen,  artificial  respiratory  aid  can  be 
supplied  with  greater  facility  than  through  a  tracheotomy  wound.  Should 
the  bronchoscopist  prefer  tracheotomv  it  never  need  be  done  under  gen- 
eral anesthesia :  and  in  a  dyspneic  case  general  anesthesia  is  utterly  un- 
justfiable  because  as  soon  as  anesthesia  begins,  respiration  ceases,  owing 
to  the  loss  of  the  aid  of  the  accessory  respiratory  musculature.  Cocaniza- 
tion  of  the  trachea  and  bronchi  may  be  used  for  trachcotomic  bronchos- 
copy in  adults ;  no  general  anesthetic  is  necessary. 

General  rules  for  local  anesthesia.  Anesthetic  adjuncts,  such  as 
adrenalin,  antipyrin.  and  \arious  S3nthetic  compounds,  the  author  has 
never  used;  consequently,  he  cannot  formulate  any  rules,  even  in  a  sug- 
gestive way,  and  he  is  compelled  to  rely  upon  Drs.  Ingals.  Coolidge,  May- 
er, Alosher.  W'inslow.  Vankauer,  Casselberry.  and  other  eminent  co- 
workers to  supply  the  deficiency.  Doubtless,  adrenalin  by  the  ischemia 
which  it  induces,  increases  anesthesia  and  also  prolongs  it  bv  slowing 
the  carrying-away  of  the  cocaine  by  the  blood.  I'.roniides  in  large 
doses,  some  hours  beforehand,  as  suggested  to  the  author  by  Dr.  Frank 
D.  Sanger,  of  Baltimore,  have  a  marked  effect  in  lessening  cough  re- 
Ilex  and  lessening  the  amount  of  cocaine  needed.  Morphine  has  this  also, 
but  its  use  is  objectionable  because  of  after-nausea:  and  in  cases  where 


ANESTIirSIA   l-OR  1'|;KI)K.\I.  K.NU0SC0I'\'.  01 

repeated  sittings  arc  necessary,  there  is  risk  of  drug  habit,  lieruin  is  an 
adjunct  useful  in  some  cases.  Xone  of  these  antibechics  should  be  used 
in  such  large  doses  as  to  abolish  the  cough-reflex  for  a  long  time  be- 
cause, as  the  author  has  frequently  pointed  out.  the  cough-reflex  is  the 
watchdog  of  the  lungs,  (|uicl<l\-  ridtling  the  lungs  of  irritati\e  and  infective 
materials 

For  esophagosco])y,  local  anesthesia  is  needless.  If  used  at  all.  its 
application  should  be  limited  to  the  epiglottis  and  laryngo-pharj^nx  (not 
hvjjo-pharvnx  ).  The  esophagus  is  insensitive  as  anyone  may  determine 
for  himself  by  swallowing  very  hot  coti'ee.  After  the  pharynx  is  passed 
the  burning  sensation  ceases,  though  sometimes  it  is  felt  again  slightly 
when  the  stomach  is  rcachcil. 

KL'LI'.S   I'OU  TIIK   rsi':  OF   C'OCAI  i\"K. 

(1)  Cocaine  should  never  be  used  in  infants  or  small  children. 

(2)  Its  use  should  be  a\oided,  if  possible,  in  all  cases,  such  as 
cases  of  papillomata.  in  which  frec|uent  sittings  are  necessary. 

f3)     The  patient  should  never  know  the  name  of  the  drug. 
(4)     The  amount  used  should  be  the  minimum  as  to 

(a)  Strength  of  solution. 

(b)  Uuantity  of  solution. 

(c)  Mucosal  area  touched. 

Hence,  only  certain  highly  sensitive  areas  should  be  touched  with 
the  stronger  solutions;  the  less  sensitive  areas  receiving  only  the  weaker 
solutions,  either  by  direct  apjjlication  or  bv  the  incidental  flow  over  the 
moist  mucosal  surface  following  the  application  of  the  stronger  solutions 
to  the  highly  sensitive  areas. 

(■"))      Solutions  may  be  ap])lied  by 
( a )     Spray. 
(  b  I     Syrin.ge. 
(cl      Painting -;_\ringe  (l!nuiings|. 

(d)  Applicator    carrying  cotton   or   gauze   saturated,   but    not 
dripping,  with  solution. 

Preference  should  be  gi\en  to  either  or  both  of  the  ki'^t  two  methods 
as  being  more  jirecise.  The  spray  is  useful,  if  the  operator  desires  to  use 
any  anesthetic  at  all  in  cases  of  foreign  body  in  the  larynx,  as  a  spray  is 
much  less  liable  to  dis])lace  the  intruder  than  a  swab;  but  for  this  very 
reason  any  form  of  anesthesia  had  better  be  <imitted  in  cases  of  laryn- 
geally  lodged  foreign  bodies. 

(('))  The  stomach  should  always  be  empty,  not  only  because  the 
tendency  to  vomiturition  and  vomiting  are  thus  lessened;  but  because,  as 
proven  bv  llrimings,  absorjilion  of  cocaine  i-^  thus  lessened. 


^ 


Oe  ANUSTHESIA  FOR  PHUORAL  ENDOSCOPV. 

The  author's  technic  for  local  aui-sthcsia.  The  author  has  two  por- 
celain jars,  thick  and  heavy,  though  small,  (about  3  c.  c.)  carried  with 
the  instrumentarium.  In  one,  an  8  per  cent  cocaine  solution  is  freshly 
prepared,  and  in  the  other  a  20  per  cent  solution.  The  latter  is  known 
by  a  red  band  around  the  jar,  burned  into  the  porcelain.  Fig.  43.  This 
solution  is  used  only  with  extreme  caution  and  in  small  quantity.  In  no 
case  are  the  jars  refilled,  hence  the  total  quantity  is  always  limited:  and, 
of  course,  most  of  it  is  thrown  away  in  the  swabs  and  escapes  with  the 
secretions,  so  that  only  a  very  small  portion  of  the  solutions  is  absorbed 
by  the  patient.  Used  in  this  way,  the  author  has  never  had  a  serious 
symptom.  This  method  was  adopted  after  the  death  of  a  child  in  rhyth- 
mic, symmetrical  convulsions  one  hour  after  the  removal  of  a  papilloma 
of  the  larynx  under  cocaine  anesthesia.  He  has  never,  however,  used 
cocaine  in  children  since,  and  never  will.  All  of  his  endoscopy  on  chil- 
dren under  seven  years  of  age  is  done  without  any  anesthetic,  general  or 
local,  except  in  a  very  few  cases  of  complicated  foreign-body  extractions, 
such  as  the  closure  of  safety-pins.  The  author's  method  of  application 
for  local  anesthesia  is  as  follows :  With  a  dossil  of  cotton  held  in  a 
Sajous  larj'ngeal  forceps,  the  larj'ngo-pharynx  is  swabbed  with  an  8  per 
cent  solution  of  cocaine,  by  sense  of  touch,  without  a  mirror  After  two 
minutes'  wait,  the  laryngoscope  is  introduced,  and  the  anterior  and  pos- 
terior surfaces  of  the  epiglottis  are  painted  with  a  small  gauze  sponge 
(Fig.  27)  saturated  with  the  20  per  cent  cocaine  solution  and  carried  in 
with  a  sponge  holder  (Fig.  2.")).  A  fresh  sponge  is  saturated  and  car- 
ried through  the  glottis  and  down  the  trachea.  After  a  two  minutes' 
wait,  the  bronchoscope  is  introduced  if  desired  and  deeper  applications 
made  as  necessary.  The  posterior  tracheal  wall  and  the  neighborhood  of 
the  bifurcation  are  the  sources  of  much  reflex-cough,  and  the  bronchus 
to  be  entered  may  need  an  application  ;  but  the  skillful  operator  will 
often  dispense  with  local  anesthesia  after  the  first  application,  as  the 
cough-reflex  in  many  instances  soon  ceases  to  be  troublesome,  and  a 
certain  amount  of  cough  need  not  interfere  with  work.  In  case  of  im- 
pacted foreign  bodies,  it  is  of  advantage  to  hold  the  swab  in  contact  with 
the  surrounding  tissues  for  about  half  a  minute. 

Technic  of  general  anesthesia.  For  esophagoscopy  and  gastroscopy. 
ether  or  chloroform  may  be  started  by  the  usual  method  and  continued 
by  dropping  upon  a  folded  bit  of  gauze,  several  layers  thick,  laid  over 
the  mouth  after  the  tube  is  introduced.  Undoubtedly,  there  is  a  remote 
risk  from  the  inflammability  of  ether,  which  is  too  often  forgotten. 

For  tracheo-bronchoscopy.  ether  or  chloroform  may  be  started  in  the 
usual  way  and  continued  by  holding  a  gauze  sponge  with  a  hemostat  in 
front  of  the  tube,  though  this  means  frequent  interruption  of  the  work 


ANESTHKSIA  FOK  ri-UOKAL  ENDOSCOPV.  59 

as  well  as  of  the  anesthetic.  So  far  as  interrui)tions  of  the  anesthetic  are 
concerned,  they  are,  in  the  author's  opinion,  factors  of  safety,  if  care  be 
taken  to  avoid  excessively  deepening  the  anesthesia  to  prolong  the  inter- 
val. Or,  after  starting  in  the  usual  way,  chloroform  and  ether  may  be 
continued  by  means  of  the  Buchanan  attachment  (Fig.  17)  directly  to 
the  bronchoscopic  tube,  care  being  taken  carefully  to  time  the  insuffla- 
tions properly  in  relation  to  inspiration.  It  is  preferable  to  start  with 
ether  and  continue  with  chloroform,  which  is  relatively  (juite  safe  after 
the  stimulant  effects  of  ether  are  established. 

ADDITIONAL  NOTES  ON  GENERAL  ANESTHESIA  FOR  PERORAL  ENDOSCOPY. 

The  foregoing  is  reprinted  here  exactly  as  presented  and  discussed 
at  the  meeting  mentioned.  The  following  observations  may  be  added 
and  some  points  may  be  emphasized. 

A  serious  error  has  crept  into  medical  literature  in  regard  to  an- 
esthesia for  direct  laryngoscop\-,  and  unfortunately,  error  in  medical  lit- 
erature persists  and  is  handed  down  from  author  to  author  long  after 
men  doing  the  work  realize  the  error.  The  statement  has  been  repeatedly 
made  that  general  anesthesia  is  necessary  for  direct  laryngoscopy  in 
children,  .\othing  could  be  farther  from  the  truth,  because  in  children, 
no  anesthetic,  general  or  local,  is  required  in  anv  case  for  direct  laryn- 
goscopy. In  certain  adults  with  short,  thick  necks  and  of  a  very  muscu- 
lar tyi)e,  with  engorged  irritable  throats  it  requires  a  high  degree  of  skill 
to  do  accurate  work  by  direct  laryngoscopy,  even  with  local  anesthesia. 
In  such  cases  there  is  ami)le  justification  for  the  beginner  to  use  a  general 
anesthetic,  provided  there  is  no  dyspnea  and  no  obstruction  in  the  larynx. 
l!ut  in  children,  no  one  is  worthv  of  the  name  of  direct  laryngoscopist  if 
he  cannot  examine  the  larynx  of  any  child  without  any  anesthetic,  gen- 
eral or  local.  Children  with  papillomata  are  c|uite  likely  to  die  on  the 
table  if  a  general  anesthetic  be  given,  unless  the  operator  is  exceedingly 
prompt  with  a  bronchoscopic  oxygen  insufflation,  or  a  jiromju  tr.icheot- 
omy  with  insufTlation  of  amyl  nitrite  and  oxygen. 

In  the  case  of  a  combative  child  who  is  also  dyspneic  it  must  be 
remembered  that  compelling  the  child  to  undergo  the  anesthetic  will  be 
even  more  than  usually  dangerous,  for  dyspnea  is  always  increased  by 
exertion.  If  a  struggle  on  the  part  of  the  patient  ends  in  succumbing  to 
the  anesthetic  the  danger  is  so  great  that  only  cjuick  work  will  save  the 
child.  If  on  the  other  hand  the  struggle  had  ended  with  the  insertion  of 
a  bronchoscope  instead  of  the  administration  of  an  anesthetic,  the  child 
would  be  safe  at  the  end  of  the  struggle  instead  of  moribund. 

The  author  has  never  seen  a  case  of  arrested  respiration  by  pres- 
sure on,  or  irritation  of,  the  ])crii)heral  nervous  respiratory  mechanism. 


(>0  ANESTHESIA  1-OK  PEKORAI.  EiNDOSCUPY. 

such  as  the  so-called  "vagus  reflex."  Such  arrest  is,  in  liis  opinion,  al- 
ways due  to  occlusion  of  the  air  passages,  for  the  following  reasons. 
Respiratory  arrest  never  occurs  in  work  without  anesthesia  unless  the 
air  passages  are  occluded  initil  the  jjatient  asphyxiates.  On  the  other 
hand,  when  apnea  vera  has  occurred  in  the  cases  that  have  come  to  the 
writer's  knowledge,  it  has  always  been  under  deep  anesthesia,  when,  of 
all  times,  the  patient  should  be  less  susceptible  to  reflex  arrest  of  res- 
piration by  presence  of  the  endoscopic  tube.  Therefore,  the  author  be- 
lieves that  the  occasionally  given  "vagus  reflex''  as  a  cause  of  death  in 
esophagoscopy  or  "laryngeal  reflex"  in  bronchoscopy,  are  unwarranted 
by  the  facts. 

Angiomata,  edematous  polyps,  and  a  few  vascular  growths  will  shrink 
so  completely  under  cocaine  as  to  render  accurate  removal  impossible. 
When  this  is  found  to  be  the  case  a  general  anesthetic  will  be  necessary. 

Small  growths  projecting  from  the  ventricle  in  adults  may  be  very 
readily  hidden  by  the  over-riding  projection  of  the  ventricular  band. 
This  projection  is  very  much  more  pronounced  under  even  thorough 
anesthetization  by  local  means,  so  that  unless  extremely  expert,  the 
operator  will  require  the  use  of  general  anesthesia,  which  has  the  eft'ecl  of 
lessening  very  much  the  projection  of  the  ventricular  band.  Esophagos- 
copy  ujion  the  struggling,  resistant  patient  whose  pharyngoesophageal 
musculature  is  in  a  state  of  spasm,  is,  in  the  hands  of  the  less  skillful, 
not  without  risk  unless  care  is  exercised.  The  skillful  esophagoscopist 
will  do  it  without  the  slightest  danger.  The  ordinary  risks  of  anesthesia 
are  very  much  enhanced  by  risks  of  respiratory  arrest,  be  this  from 
reflex  inhibition  or  mechanical  obstruction  of  the  trachea  from  the  bulk 
of  the  tube  or  of  the  foreign  body  or  both,  or  from  other  causes.  Spas- 
tic conditions  of  the  hypo-pharyngeal  and  esophageal  musculature, 
whether  from  the  presence  of  a  foreign  bodv  or  other  causes,  are  com- 
])letely  relaxed  by  general  anesthesia.  For  esophagoscojiv  the  author 
would  ad\ise,  if  any  anesthesia  is  desired,  ether  insufflation  with  the 
Elsberg  apparatus  (Fig.  57  )  because  it  introduces  an  element  of  safety 
which  has  never  ])ertained  to  esophagoscopy  under  general  anesthesia 
before,  except  in  the  hands  of  the  most  skillful.  As  elsewhere  men- 
tioned, there  have  been  in  the  practice  of  various  operators  a  numlier  of 
deaths  on  the  table  from  arrest  of  respiration  during  esophagosco]5v  un- 
der general  anesthesia.  This  occurred  es])ecianv  in  foreign-bodv  cases 
where  the  bulk  of  the  tube  and  the  Inilk  oi  the  foreign  body  together  com- 
liressed  the  trachea  when  the  esophagoscope  over-rode  the  foreign  body. 
The  author  is  not  prepared  to  advocate  the  Elsberg  anesthesia,  or  any  oth- 
er method,  to  overcome  the  faults  of  technic  in  esophagoscopy ;  but  it  cer- 
tainh    insures  safety,  so  far  as  respiratory  arrest  is  concerned,  to  have 


ANESTiiKsiA  loR  PKuouAi,  i:Nnnscopv. 


f)l 


a  silk  woven  catheter  in  the  traclica  insnring  the  supplNini;  of  air  to 
the  hnigs.  ami  assuring  the  impossibiHty  of  complete  obliteration  of  the 
tracheal  lumen,  for  enough  lumen  must  exist  at  both  sides  of  the  tube 
to  permit  the  return-flow  of  air.  The  author  does  not  hesitate  to  say  to 
those  who  wish  to  use  general  anesthesia  for  esophagoscopy  that  a  death 
on  the  table  is  practically  impossible  with  ether  insufflation.  Of  course, 
the  presence  of  the  catheter  in  the  trachea  would  render  possible  trauma 
by  the  tube  moutl;.   but  only  liy   the  grossest  technical   faultiness. 

In  man_\-  cases  of  foreign  body  in  the  esophagus,  the  foreign  body 
is  [ircvented  from  going  downward  by  muscular  contractions.  There- 
fore, if  a  general  anesthetic  is  given,  the  relaxation  of  this  clonic  con- 
traction by  the  anesthetic  permits  the  foreign  body  to  escape  downward. 
The  author  believes  this  to  be  one  of  the  reasons  whv  it  has  so  rarelv 


Fi(f.  57.     Mlsljcrg  apparatus   for  intratracheal   iiisutTlation  ether  anesthesia. 


happened  in  the  I'ittsburgh  Clinic  that  a  foreign  body  has  been  lost 
downward.  In  the  absence  of  anesthesia,  the  ])rcsence  of  the  tul)e  ex- 
cites still  greater  spasmodic  contractions  of  the  esophageal  wall  and  the 
foreign  body  is  held  all  the  more  tightly,  which  gives  the  operator  a 
good  chance  to  approach  it  with  the  lube  and  seize  it  wilii  the  forceps. 
Out  of  20(i  cases,  only  S  went  down,  and  of  these,  only  3  went  down 
after  the  commencement  of  the  esophagoscopy.  Of  the  :?,  2  were  under 
general  anesthesia,  which  leaves  but  a  single  case  where  a  foreign  body 
escaped  dounw.inl  during  esophagoscopy  witlunu  anesthesia,  general  or 
local. 

In  tlie  l;ist  loT  bronchoscopies  and  esophagoscopies  fur  furcign  bodies 
in  children  under  (i  years  of  age,  done  in  the  I'iltsburgh  Clinic,  no  an- 
esthetic, general  or  local,  has  been  used.  .\  number  of  adolescent  and 
adult   cases   \v,\\v  been   done   also  without   anesthesia,  general   or  local. 


fi2  ANESTHESIA  FOR  PERORAL  ENDOSCOPY. 

Ten  of  the  cases  have  been  in  the  children  of  physicians,  every  one  of 
whom  expressed  his  delight  that  no  anesthetic  was  used,  and  in  each 
instance  the  physician  was  present  at  the  removal  of  the  foreign  body 
from  his  own  child.  Surely  this  is  the  best  evidence  that  there  is  no 
very  severe  ordeal  connected  with  bronchoscopy  and  esophagoscopy  with- 
out anesthesia.  There  is  no  question  in  ihe  author's  mind  but  that  all 
forms  of  anesthesia,  general  or  local,  introduce  a  great  element  of  dan- 
ger to  the  handling  of  foreign-body  cases  in  children,  more  especially 
when  chloroform  is  used.  In  adults,  with  ether,  the  risk  in  cases  free 
from  dyspnea  is  probably  very  slight.  The  ordinary  risks  of  chloro- 
form anesthesia  are  enormously  increased  in  esophagoscopy,  for  which 
chloroform  is  absolutely  contra-indicated. 

The  author  has  had  one  post-operative  death  from  general  anes- 
thesia in  endoscopy.  A  man  of  46  died  about  one  week  after  direct 
laryngoscopy  for  the  removal  of  a  laryngeal  neoplasm.  There  was  a 
gangrenous  bronchitis  due  to  delayed  chloroform  poisoning.  He  had  an 
old  bronchial  history.  As  he  took  ether  badly,  chloroform  was  substi- 
tuted. Not  doing  well  with  this,  the  anesthesia  was  abandoned,  the 
operation  being  done  without  an  anesthetic.  As  there  was  no  instru- 
mentation whatever  below  the  laryn.x,  and  as  the  death  occurred  a  week 
after  the  laryngeal  operation,  the  author  cannot  see  that  endoscopy  can 
be  blamed.  It  is  the  only  death  directly  or  indirectlv  due  to  general 
anesthesia  in  the  author's  entire  endoscopic  experience.  The  only  rea- 
son for  using  a  general  anesthetic  was  that  the  small  growth  was  very 
vascular  and  edematous,  hence,  shrunk  so  as  to  be  invisible  when  cocain- 
ized. The  comparatively  trixial  nature  of  the  growth  rendered  the  oc- 
currence all  the  more  distressing.  The  author  had  one  toxic  death  from 
idiosj'ncrasy  to  cocaine  in  a  child  of  4  years.  Death  occurred  after  rhyth- 
mic convulsions  three  hours  after  removal  of  laryngeal  Dapillomata  for 
which  an  8  per  cent  cocaine  solution  had  been  used.  These  two  deaths 
both  occurred  in  the  early  years  of  peroral  endoscopy  and  led  the  author 
to  develop  to  the  utmost  the  means  of  working  without  anesthesia,  and 
he  was  astonished  at  the  utter  Heedlessness  of  any  anesthetic  in  children. 

As  all  opium  derivatives  have  a  toxic  effect  upon  the  respiratory 
center,  their  use  in  any  case  in  which  chloroform  is  expected  to  be  given 
is  distinctly  contra-indicated  lest  the  synergistic  toxic  effect  cause  re- 
spiratory arrest.  If  the  endoscopist  insists  on  their  use,  he  should  be 
prepared  promptly  to  apply  bronchoscopic  oxygen  insufflation,  for  ordi- 
nary artificial  respiration  is  illogical  and  useless  when  the  respiratory 
center  is  paralyzed  with  drugs.  As  children  are  particularly  susceptible 
to  the  action  of  opium  derivatives,  the  danger  is  particularly  great,  and 
there  is  very  good  evidence  to  show  that  some  of  the  unexplained  deaths 


ANESTHESIA  FOR  I'KROKAI,  ENDOSCOPY. 


63 


after  hronchoscopy,  which,  by  the  way,  always  have  occurred  in  cases 
in  which  an  anesthetic  had  been  given,  were  probably  due  to  paralysis 
of  the  respiratory  center  by  the  combined  toxic  action  of  the  chloroform 
with  morphine  or  with  codein.  Atropin  counteracts  the  effect  of  mor- 
phine to  some  extent  in  this  direction,  but  it  would  seem  that  to  give 
chloroform,  codeine,  cocaine,  adrenalin,  morphine  and  atropine  is  loading 
up  the  organism  with  a  great  many  drugs.  In  the  case  of  children  it  is 
an  utterly  needless  lot  of  drugs,  as  any  one  will  admit  who  has  seen 
bronchoscopy  in  children  without  anesthesia,  general  or  local.  In  ado- 
lescents, morphine  may  be  used  in  conjunction  with  ether  or  the  usual 


Fig.  58.     Schema  illustrating  the  method  of  hyoid  bone  elevation  to   free  the 
air  passages  during  general  anesthesia. 


morphine  and  atropine  hyjiodcrmic  combination  may  be  tised,  though  in 
uncomjjlicated  cases  no  anesthetic  is  necessary.  In  adults  this  combina- 
tion is  useful  especially  in  difficult  foreign-body  cases.  The  use  of 
atropine  as  advocated  by  Ingals  to  lessen  secretions  during  bronchoscopy, 
not  only  checks  secretions  but  is  a  valuable  stimulant  to  both  the  cardiac 
and  respiratory  centers,  so  that  it  would  seem  to  be  advantageous  from 
a  number  of  points  of  view.     The  safety  of  scopolamine  is  unproven. 

When    using  general   anesthesia   and   the   patient   does   not   take   it 
well,  the  best  thing  to  do  is  promptly  to  insert  a  silk-woven  catheter  and 


04  ANESTHESIA  FOR  PERORAL  ENDOSCOPY. 

proceed  witli  the  anesthesia  by  ether  insufflation  with  th.e  Elsberg  or 
similar  apparatus.  If  for  any  reason  this  is  considered  undesirable  or 
the  apparatus  is  not  at  hand,  the  breathing  may  be  promptly  cleared  by 
hyoid-bone  elevation,  using  either  the  direct  laryngoscope  or  the  fore- 
finger. Fig.  ."jS,  as  described  by  Dr.  Ellen  J.  Patterson  (I!ib.  42!0,  the 
head  being  forced  into  extreme  extension.  This  extension  of  itself  will 
usually  clear  the  airway  as  shown  by  Hobart  A.  Hare. 

An  interesting  case  of  tracheal  obstruction  by  an  aneurysmal  com- 
pression, plus  a  small  mass  of  mucus  is  reported  by  Pratt  (Uib.  -iSG). 
During  anesthesia  the  patient  became  cyanotic  in  spite  of  violent  respira- 
tory^ muscular  activity.  Insertion  of  an  intratracheal  tube  gave  immediate 
relief.  No  case  of  paralysis  of  the  larynx,  even  if  only  monolateral,  should 
be  given  a  general  anesthetic  except  by  intratracheal  insufflation.  If  this 
cannot  be  arranged,  the  patient  sliould  be  tracheotomized.  Hence,  every 
adult  patient  should  be  examined  with  the  throat  mirror  before  anesthesia, 
and  the  necessity  becomes  doubly  imperative  before  goitre  operations.  A 
number  of  fatalities  have  occurred  from  neglect  of  this  precaution. 

Da\is  reports  the  use  of  the  intra-muscular  injection  of  ether  into 
the  buttock  of  a  child  primarily  rendered  unconscious  by  ethylchlorid. 

Joseph  A.  Stucky  and  William  Stuckv  have  used  rectal  ether  anes- 
thesia with  excellent  results. 

ADDITIONAL    NOTES   ON    LOCAL   ANESTHESIA. 

If  local  anesthesia  be  used  in  children,  the  author  urges  care  and 
gentleness  in  its  application  especially  to  the  subglottic  region  of  children. 
For  direct  laryngoscopy  in  adults,  some  endoscopists  have  proposed  in- 
jecting an  anesthetic  solution  with  a  syringe  armed  with  a  hypodermic 
needle  into  the  laryngeal  tissue.  This  the  author  believes  to  be  unneces- 
sary as  contact  anesthesia  will  suffice  for  all  cases  if  the  patient's 
eyes  are  covered  and  the  operator  can  get  the  patient  to  fix  his  attention 
on  deep  breathing.  Some  very  apprehensive  patients  will  anticipate  cough 
at  the  contact  of  the  instrument  and  will  cough  semi-voluntarily  in  the 
absence  of  a  true  reflex,  if  they  are  allowed  to  see  the  instrument  enter 
through  the  speculum.  If  it  is  desired  to  anesthetize  locally  for  esophagos- 
copy  the  best  method  is  to  make  a  preliminary  application  of  an  S  per 
cent  solution  over  the  epiglottis  and  into  the  larj'ngopharynx  with  cotton 
on  the  Sajous'  applicator.  Then  either  the  laryngeal  or  the  esophageal 
speculum  is  passed  and  the  right  pyriform  sinus  is  swabbed  once  with  a 
20  per  cent  solution  on  a  gauze  sponge  held  in  a  straight  sponge-holder 
and  allowed  to  remain  for  about  a  minute.  Examination  mav  begin  one 
minute  later.  Cocaine  tablets  may  be  sterilized  by  placing  a  formalde- 
hyde pastille  in  the  bottom  of  a  bottle  in  which  the  tablets  are  kept. 


ANF.STHKSIA  TOR   l'i:i;OKAl.  KNDOSCOPY.  C5 

.  hiestlicsia  for  the  use  of  the  esopliojieal  speculiiiii.  \utv  llie  use  of 
the  eso])li;igeal  speculum,  local  anesthesia  is  not  necessary,  but  lessens 
the  slight  discomfort.  General  anesthesia  is  not  necessary,  l)ut  if  deep, 
affords  a  very  much  licttcr  \ie\v  of  the  ujjper  end  of  the  esophagus  be- 
cause it  prevents  spasm  of  the  inferior  constrictor  and  of  the  esophageal 
musculature  in  general.  Tlie  autiior's  custom,  however,  is  to  use  no 
anesthesia,  general  or  local,  in  cither  adults  or  children.  l'"or  local 
anesthetization,  the  method  just  given  for  esophagoscopy  may  be  used. 

For  gastroseopy,  no  anesthetic,  general  or  local,  is  needed  to  enable 
the  skillful  esophagoscopist  to  put  the  gastroscope  into  the  stomach  ;  but 
once  there,  in  the  absence  of  the  complete  rela.xation  of  general  anesthesia, 
the  gastroscope  remains  fixed  because  of  the  muscular  activity  of  the 
diaphragmatic  musculature.  To  gain  full  relaxation  of  this  musculature 
and  of  the  abdominal  wall,  in  order  that  the  gastroscope  mav  be  freely 
movable,  jirofound  anesthesia  is  esscnti;d.  Intratracheal  ether  insuti'la- 
tion  is  most  convenient. 

.\n'Kstiii:tizix(',  a  traciii;ot().mizi;i)  i'.\tiknt. 

Xo  hesitation  need  be  felt  in  gi\ing  a  general  anesthetic  to  a  trache- 
otomized  patient  so  far  as  the  tracheotomic  wound  is  concerned.  Such 
a  patient  is  far  safer  than  one  not  tracheotomized  and  there  is  no  trouble 
with  the  tongue  or  the  tissues  attached  to  the  hyoid  bone  falling  back- 
ward and  downward  obstructing  breathing.  They  take  the  anesthetic 
quietly.  It  has  been  necessary  many  times  for  Dr.  I'aiterson  to  remove 
tonsils  from  patients  under  treatment  for  laryngeal  stenosis.  In  every 
instance  the  patient  went  under  ether  (|uietly  and  was  kept  fully  under 
until  the  operation  was  completed,  all  \c5sels  twisted  and  oozing  stop])ed. 

The  technic  is  simjile.  .\  fold  of  gauze  is  laid  o\er  the  tracheotomy 
cannula  and.  if  the  laryngeal  stenosis  is  not  complete,  another  over  the 
mouth.  The  etlier  is  dropped  upon  both  pieces  so  tli;il  no  matter  which 
way  air  is  taken  in,  it  carries  the  ether  with  it.  It  is  necessary  to  see 
that  a  good  stout  tape  is  securely  attached  to  the  cannula  and  tied  back 
of  the  neck  in  the  regular  way.  One  assistant  or  nurse  trained  to  tracheal 
work  should  be  stationed  to  give  undivided  attention  to  th.c  c.innnla  ;ind 
secretions  coming  from  it. 

INSUFFLATION    ANKSTIIKSIA. 

The  experiments  of  Melzer  and  .Auer  and  the  developments  bv  hlls- 
berg,  janeway.  Carrel.  Ouinby,  Cotton,  Robinson,  and  others  have  placed 
intratracheal  insufflation  anesthesia  on  ;i  tlrm.  scientific  and  practical  basis. 
Tli\rotom\  can  be  readilv  done  under  local  anesthesia  bv  those  who  fullv 


66 


ANESTHKSIA    FOR    PF.ROKAI,    EXDOSCOPY. 


understand  the  technic  of  infiltration.  Much  time,  however,  will  be 
saved  by  insufflation  anesthesia ;  and  the  strong  return-flow  keeps  the 
blood  and  secretions  from  gaining  an  entrance  to  the  lower  air-passages. 
This  return-flow  is  in  ever\-  way  more  advantageous  for  the  purpose 
than  the  use  of  the  tampon  cannula,  the  Trendelenberg  position,  or  even 
the  excellent  plan  of  JMoure,  using  the  ordinary  cannula  with  a  gauze 
tampon  in  place  above  the  cannula.  It  is  surprising  how  little  room  the 
insufflation  catheter  introduced  through  the  mouth  requires  in  the  opened 
lan,nx.  It  lies  close  along  the  posterior  wall  in  a  region  which  it  is  not 
necessary    to    invade,    because   thyrotomy    is   apt    to   be   unsuccessful    in 


Fig.  sg.  Insufflation  ether  anesthesia  with  the  Elsberg  apparatus  in  the  clinic 
of  Dr.  Otto  C.  Gaub.  The  anesthetist,  Dr.  Wade  Elphinstone,  has  exposed  the 
larynx  and  is  about  to  introduce  the  silk  woven  catheter  in  a  case  of  head  surgery. 
Note  the  full  extension  with  the  head  on  the  table. 


malignancy  if  the  involvement  has  reached  the  party  wall.  Should  it  be 
necessary  in  benign  conditions  to  operate  upon  this  wall,  it  is  very  easy 
to  displace  the  catheter  sideways.  In  malignant  cases,  if  it  is  found  that 
the  growth  is  not  removable  by  thyrotomy  and  that  a  laryngectomy  is 
necessary,  it  is  very  easy,  after  amputating  the  trachea,  to  insert  the 
insufflation  catheter  into  the  cut-end  of  the  trachea  and  thus  earn,-  out  a 
complete  laryngectomy  with  the  anesthetist  entirely  out  of  the  way  and 
with  no  loss  of  time.     Dr.  Otto  C.  Gaub  and  Dr.  W.  P.  Barndollar  have 


ANESTHKSIA    J-OR    PERORAI,    l-.NDOSCOPY.  G7 

demoiistratt'd  the  great  advantage  of  the  intratracheal  insulllation  method 
of  anesthesia  in  the  extirpation  of  a  nasopharyngeal  fibroma,  which  was 
so  large  that  it  pressed  the  soft  palate  forward  on  the  tongue  and  pro- 
duced dangerous  dyspnea.  Tf  to  this  had  been  added  the  free  flow  of 
blood  usual  in  such  cases,  the  i)atient  would  have  been  asphyxiated.  On 
the  contrary,  in  this  case,  from  the  moment  the  insufflation  was  started 
the  patient's  color  was  good.  All  blood  and  clots  came  back  out  of  the 
mouth  and  the  operation  required  only  a  few  minutes  because  it  was  un- 
interrupted. The  presence  of  the  catheter  in  the  mouth  produced  no  in- 
convenience whatever.  The  day  of  tracheotomy  preliminary  to  the  extir- 
pation of  nasopharyngeal  fibromata  is  past.  In  all  prolonged,  bloody, 
nasal.  ])haryngeai.  buccal,  and  laryngeal  operations  insufflation  ether  an- 
esthesia diminishes  the  time  of  operation  at  least  three-fourths.  In 
aural,  ophthalmic,  and  all  forms  of  general  head  and  neck  surgery  the 
distant  removal  of  the  anesthetist  from  the  field  is  not  only  a  time-saving 
convenience,  but  it  eliminates  a  serious  infective  risk.  In  general  sur- 
gical operations  requiring  a  jirone  jiosition  of  the  patient,  insufflation  an- 
esthesia is  ideal.  In  the  short,  thick-necked,  alcoholic  "full-blooded''  type 
of  patient  that  ordinarily  behaves  so  badly  under  ether  by  the  open 
method,  insufflation  anesthesia  gives  a  quiet  and  perfect  anesthesia  impos- 
sible by  any  other  means. 

All  the  foregoing  classes  of  cases  are  jjarticularly  the  sphere  of  in- 
sufflation anesthesia ;  but  it  is  an  ideal  method  for  anesthesia  in  any  sort 
of  case,  because  of  its  safety  and  its  precision  and  minimization  of  dosage, 
Meltzer  refers  to  the  mouth,  pharynx,  larynx,  and  trachea  as  the  "death 
space,"'  a  particularly  expressive  term,  for  there  can  be  no  doubt  what- 
ever that  most  of  the  deaths  from  anesthesia  have  been  due,  directly  or 
indirectly,  to  purely  mechanical  obstruction  in  these  regions.  In  re- 
suscitation from  respiratory  arrest,  or  collapse,  or  cardiac  failure,  it  is 
tliis  '"death  space"  which  is  hardest  to  fight  because  of  the  difficulty  oi 
kee[)ing  up  artificial  res])irati()n  in  a  good  and  efficient  way  in  the  flabby 
state  in  which  the  tt)ngue  and  all  the  tissues  attached  to  the  hyoid  bone 
are.  at  such  times.  Some  sort  of  artificial  airway  is  essential.  In  in- 
sulllation anestliesia  the  "death  space"  is  entirely  eliminated  and  acci- 
dents presented.  In  regard  to  the  efTect  on  the  mucosa  of  the  air  pas- 
sages, ihc  .lutluir  is  .ible  to  state  from  post-anesthetic  laryngoscopy  in  so 
cases  that  there  is  no  reaction  in  the  larynx  from  the  ])resence  of  the 
insufflation  tube,  even  in  a  jirolonged  anesthesia  by  insufflation.  In  quite 
a  luunbcr  of  the  cases  anestlu-ti/ed  by  the  (irdinary  open  mclhix]  there 
has  been  quite  a  great  deal  of  local  laryngeal  reaction,  probably  froiu 
ether  mucus  bubbling  back  and  forth  in  the  lar\-nx.  so  that  from  an  ob- 
ser\a1ion  of  these  80  cases  the  .lutlmr  is  prepared  to  s.-iy  that   there   is 


68  ANKSTIIESIA  FOR  PEKORAL  ENDOSCOPY. 

less  irritation  of  the  lar}'nx  from  an  intra-traciieal  insufflation  than  from 
an  anesthesia  of  corresponding  duration  bv  the  open  method.  In  the 
mucosa  of  the  trachea  and  bronchi  in  sixteen  cases  there  was  less  mucosal 
reddening,  and  not  nearly  as  much  mucus  as  is  usually  seen  in  patients 
etherized  by  the  open  method.  Bronchoscopic  observations  of  the  author 
have  proven  that  the  "ether  mucus"  of  the  ordinary  open  method  of  ad- 
ministration is  from  the  salivary  glands  and  not  from  the  tracheo-bron- 
chial  mucosa.  True,  patients  etherized  by  the  open  method  are  found 
to  have  their  trachea  and  bronchi  full  of  mucus,  but  it  has  been  aspirated 
from  above  o\\ing  to  abolition  of  the  cough-reflex.  The  management 
of  the  apparatus  varies  so  much  with  the  form  of  apparatus,  and 
the  apparatus  have  become  so  numerous,  that  the  technical  manage- 
ment of  each  cannot  be  given  here.  Explicit  directions  reprinted  from 
the  writings  of  the  surgeons  who  have  devised  the  instruments  are  sup- 
plied by  the  makers.  The  dosage  is  regulated  according  to  the  effect  on 
pulse  respiration,  reflexes,  color  of  skin,  etc.,  as  in  any  other  method 
of  administration.  The  great  difference,  however,  is  the  quickness  of 
response  to  increase,  diminution,  or  withdrawal  of  the  ether-content  of 
the  insufflated  air.  The  anesthesia  can  be  deepened,  shallowed,  or  the 
patient  brought  out  with  a  promptness  and  precision  that  seems  incred- 
ible to  those  accustomed  to  the  slow  response  inevitable  with  other  meth- 
ods in  all  of  which  control  is  befogged  by  the  unknown  and  unknowable 
residual  ether-content  of  the  air  and  food  passages.  \\'ith  insufflation 
there  is  no  fluid  ether  anywhere  in  the  body,  except  that  already  absorbed 
into  the  blood,  and  as  soon  as  the  ether  is  shut  oiT,  the  warmed  air-cur- 
rent blows  out  the  ether-vapor  from  the  air  passages.  The  author's  first 
experience  with  insufflation  anesthesia  was  with  the  insufflation  attach- 
ment to  the  bronchoscope  (Fig.  K)  suggested  to  the  author  by  Dr.  T. 
Drysdale  Buchanan.  (Bib.  22!)).  This  was  for  the  insufflation  of  chloro- 
form during  bronchoscopy  and  was  intended  simply  to  carry  on  anesthesia 
without  interruption  of  the  work  through  the  bronchoscope,  for  which 
purpose  it  is  ideal.  It  was  not  intended  for  a  method  of  anesthesia  for 
other  procedures. 

Tcchnic  of  insertion  of  intnitraclical  insufflation  tubes.*  Practical- 
ly all  authorities  are  now  agreed  that  the  larynx  should  lie  inspected  be- 
fore the  insertion  of  the  insufflation  catheter  or  tube,  for  the  purpose  of 
ascertaining  whether  or  not  there  is  disease  present  in  the  larynx,  and 
also  to  determine  the  size  of  the  larynx,  so  that  the  size  of  the  insufflation 
tube  may  be  selected  accordingly,  in  order  to  make  sure  that  there  is  an 
ample  laryngeal  lumen  around  the  tube  for  the  return-flow.     Not  only 


*This  section  contains  liberal  (luotations   from  the  author's  romniunication   to 
the  riinical  Congress  of  Surgeons  of  North   America.     Nov..   1313    (Bib.   2G6). 


ANESTHESIA  rOK  PEUOKAI.  i:xnnS0OPY.  69 

do  the  sizes  of  the  hirynges  vary  in  normal  incH\  ichials,  but  the  laryngeal 
lumen  may  be  modified  by  lesions  present  or  ])ast.  There  is  another 
reason  why  the  larynx  should  be  inspected ;  namely,  throughout  the  whole 
category  of  diseases  to  which  human  flesh  is  heir,  it  is  a  frequent  thing 
for  patients  to  date  comi)laints  from  some  particular  period,  accident 
or  operation  in  cases  in  which  the  physician  or  surgeon  is  absolutely  cer- 
tain tJiat  the  disease  existed  long  before  the  incident  blamed  by  the 
patient.  In  view  of  this,  it  Iiehooves  the  surgeon  to  know  whether  the 
larynx  is  diseased  or  not  at  the  time  liie  insufllation  catheter  is  inserted. 
( )ne  such  case  has  occurred  where  the  patient  dated  laryngeal  trouble 
from  the  taking  of  an  anesthetic  given  by  the  ordinary  open  method. 
The  ;iuthor's  own  case-records  and  sketches  showed  that  the  lar\nx  had 
been  the  seat  of  an  infiltration  of  tuberculous  origin  for  years  before 
the  anesthetic  was  given,  showing  that  the  anesthesia  was  in  no  way  re- 
sponsible, and  showing,  also,  the  necessity  of  knowing  the  state  of  the 
larynx  beforehand.  Only  one  thing  seems  to  deter  anyone  from  using 
the  method  advocated  by  Elsl)erg  of  insjiecting  the  larynx  and  passing 
the  catheter  or  tube  by  sight.  This  is  the  lack  of  confidence  in  the  abilitN' 
promptly  and  skillfully  to  expose  the  larynx  with  the  laryngeal  speculun^ 
Xo  one  cai)able  of  gi\ing  an  anesthetic  should  hesitate  for  one  moment 
abiiut  this  procedure,  if  he  will  take  the  trouble  to  pay  attention  to  a 
tew  ])oints. 

Rt"I.i;S  FOR  INSi:RTinX  ni'  IXSfl'FI.ATION  ANlCSTlt  ICSI.V. 

1 .  The  patient  should  be  fully  under  the  anesthetic  by  the  open 
method  so  as  to  get  full  relaxation  of  the  muscles  of  the  neck. 

■-'.  The  patient's  liead  must  be  in  full  extension  with  the  verte.x 
lirmiy  pushed  down  toward  the  feet  of  the  patient,  so  as  to  throw  the 
neck  ui)ward  and  bring  the  occi[iut  down  as  close  as  possible  bencith  the 
cervical  vertebrae. 

'■'>.  Xo  gag  should  be  used,  because  tlie  i)atieiit  should  be  sunicienlly 
anesthetized  not  to  need  a  gag,  .ind  because  wide  gagging  defeats  the  ex- 
posure of  the  laryn.x  by  jamming  down  the  mandible. 

4.  The  cjjiglottis  must  be  identified  l)efore  it  is  passed. 

5.  The  S])eculum  must  pass  sufficiently  far  below  the  lip  of  tlu-  epi- 
glottis so  that  the  latter  will  not  slip. 

(!.  Too  dee])  insertion  must  be  avoided,  as  in  this  case  the  speculum 
goes  jjosteiior  to  the  cricoid,  and  the  cricoid  is  lifted,  exposing  the  nujulh 
of  the  esophagus,  which  is  bewildering  until  sufiicient  education  oi  the 
eye  enables  the  operator  to  recognize  the  landmarks. 

The  most  important  thing  of  all  is  the  position  of  the  patient,  ,-uicl 
next  to  that  comes  recognition  of  the  epiglottis,  and  next  the  proper  mo- 
tion of  lifting  the  hyoid  bone  to  expose  the  larynx. 


70  ANESTHESIA    FOR    PKRORAI,    ENDOSCOPY. 

The  correct  position  will  be  understood  by  reference  to  the  illus- 
trations. In  Fig.  GO,  the  patient  is  placed  on  a  pillow  in  a  natural  posi- 
tion. The  larynx  can  readilv  be  examined  in  this  position,  if  it  is  de- 
sired merely  to  inspect  it,  and  is  useful  for  laryngeal  diagnosis  and  some 
endolaryngeal  oi<erations  ;  but  for  the  insertion  of  an  insufflation  tube, 
bronchoscope,  or  other  instrument,  it  is  absolutely  necessary  for  any  but 
the  most  expert  to  have  the  head  in  full  extension.  It  has  been  customary 
to  draw  the  head  over  the  table  to  gain  the  full  extension  in  the  Boyce 
position,  and  for  bronchoscopy  this  is  needed  for  the  purpose  of  moving 


Fig.  60. 


Fig.  61. 


Fig.  62. 


Fig.  60.  Photograph  of  patient  with  head  upon  a  pillow,  the  hca<l  fle.xed.  In 
this  position  it  is  easy  to  examine  the  larynx  with  the  laryngoscope  for  diagnosis, 
but  the  larynx  will  not  be  exposed  in  a  line  with  the  tracheal  axis  so  that  this  posi- 
tion is  not  adapted  to  the  passing  of  tubes  through  the  laryngoscope. 

Fig.  61.  The  pillow  is  removed,  the  head  is  flat  on  the  table  and  the  anesthetist 
is  be.ginning  to  force  the  head  into  the  extended  position.  The  thumbs  are  on  the 
forehead  and  the  lingers  are  at  the  side  of  the  head.  The  direction  of  motion  is 
shown  by  the  dart. 

Fig.  62.  The  anesthetist  is  lifting  with  the  tip  of  the  laryngoscope  in  the  direc- 
tion of  the  dart.  The  laryngoscope  is  always  held  in  the  left  hand.  The  right  hand, 
of  which  the  index  has  been  protecting  the  upper  lip,  has  now  received  the  catheter 
from  the  nurse.    The  head  must  be  in  lull  extension. 


the  head  and  the  bronchosco])e  abotit  so  as  to  enter  the  particular  bronchus 
desired.  But  for  the  insertion  of  the  insufflation  tube,  it  is  quite  unneces- 
sary to  have  the  head  extend  beyond  the  table,  and  in  fact  it  is  unde- 
sirable. The  author's  "elbow  rest  position,"  so  called  because  the  oper- 
ator's left  elbow  can  be  rested  upon  the  table  during  long  endo-laryngeal 
operations,  is  admirably  adapted  to  the  introduction  of  insufflation  tubes. 
All  that  is  necessary  to  do  to  the  patient  is  to  remove  the  pillow,  place  the 
thumb  of  each  hand  (as  shown  in  Fig.  (>1  )  on  the  forehead  of  the  patient 
with  the  hands  at  the  sides  of  the  head  and  then  force  the  forehead  vigor- 
ously  downward  and   backward,   causing  an   anterior   movement   of  the 


ANESTHESIA    TOR    I'KKOKAI,    KXDOSCOPY.  71 

skull  nil  the  atlas  and  throw  inj;  all  the  eerxical  vertebrae  forward  (upward 
in  the  reeumhent  position).  The  effect  of  this  is  to  throw  the  liyoid  bone 
and  all  the  tissues  of  the  neck,  including  the  larynx,  high  up  and  to  ele- 
vate the  tongue.  The  neck  and  shoulders  are  arched  up  away  from  the 
table.  In  a  fully  relaxed  [)atient.  it  is  not  necessary  for  an  assistant  to 
steady  the  head  in  this  position,  while  the  anesthetist  takes  the  speculum 
always  in  the  left  hand,  his  right  index  being  used  to  ])ull  the  upper  lip 
of  the  patient  out  of  the  way  so  that  the  li])  will  not  be  pinched  between 
the  speculum  and  the  upper  teeth.  The  spatular  end  of  the  speculum  is 
now  inserted  posteriorly  to  the  tongue  over  the  dorsum  of  which  it  is 
passed  until  the  epiglottis  comes  into  view.  The  spatular  end  is  made 
to  pass  posteriorlv  to  the  tip  of  the  epiglottis,  and  inserting  the  speculum 
a  distance  of,  on  the  average,  about  1  cm.,  the  hyoid  bone  and  all  of  the 
attached  tissues  are  lifted  by  a  motion  which  is  best  expressed  as  the 
suspension  of  the  head  of  the  patient  on  the  epiglottis  by  the  tip  of  the 
spatular  end  of  the  laryngeal  speculum.  Great  care  is  necessary  at  this 
point  not  to  use  the  upper  teeth  as  a  fulcrum  upon  which  to  pry  upward 
with  the  tip.  The  motion  is  rather  the  lifting  of  the  epiglottis  and  es- 
pecially the  hyoid  bone  by  the  tip  of  the  instrument  just  as  if  it  were 
desired  to  lift  the  patient's  neck  upward.  Hyoid  bone  elevation  opens 
the  laryngeal  door.  After  the  larynx  is  exposed,  the  right  hand  releases 
the  upper  lip,  which  is  now  safe,  and  the  catheter  of  the  desired  size  is 
handed  to  the  anesthestist  by  the  nurse  and  the  introduction  is  simple 
and  easy,  because  the  trachea  is  in  a  straight  line  with  the  laryngeal  spec- 
ulum. This  is  the  great  advantage  of  the  extended  position  with  the 
head  on  the  table.  At  first  sight,  it  might  be  thought  that  the  speculum, 
as  shown  in  Fig.  tiS,  could  not  be  in  line  with  the  axis  of  the  trachea.  It 
seems  to  be  the  erroneous  conception  quite  prevalent  among  the  profes- 
sion that  the  trachea  is  peri)endicular  in  the  neck  and  chest.  .\s  a  matter 
of  fact,  it  enters  the  chest  in  a  direction  backward  as  well  as  downward. 
as  illustrated  schematically  in  Fig.  64,  so  that  in  the  extended  position 
I)ro])er  for  the  exposure  of  the  larynx  and  the  insertion  of  anv  sort  of 
tube  into  the  trachea,  the  axis  of  the  speculum,  as  shown  in  h'ig.  (!2,  is 
I)recisely  in  line.  This  must  be  remembered  in  placing  the  patient  in 
position,  but  for  the  insertion  of  the  speculum  it  is  well  to  forget  it  and 
remember  only  that  the  motion  is  a  strong  lifting  of  the  //'/'  of  the 
sj)eculum,  as  shown  in  Fig.  (1"^.  In  some  patients  after  the  introduction 
of  the  catheter  there  may  be  a  large  amoinit  of  thick  tenacious  secretion 
enter  the  catheler  which  may  occlude  respiration  through  the  catheter, 
so  that  the  hand  held  in  front  of  it  does  not  receive  the  exjiiratorv  blast, 
leading  to  the  impression  that  the  catheter  is  not  in  the  trachea.  If  there 
is  any  doubt  on  this  point  it  is  better  to  insert  the  specuhun  and  to  lift 


72  ANESTHESIA  FOR  PERORAL  ENDOSCOPY. 

the  epiglottis  and  note  particularly  that  the  arytenoid  eminences  are 
posterior  to  the  catheter.  Oi  course  in  cases  in  which  the  patient  is  not 
deeply  anestlietized  cough  will  free  the  catheter  but  when  the  cough-re- 
tlex  is  abolished  the  ]iatient  will  breathe  on  each  side  of  the  occluded 
catheter  through  the  lumen  of  which  no  air  will  emerge  at  ordinary 
resoiratory  pressure.  If  occluded  a  fresh  catheter  may  be  substituted,  but 
in  most  instances  probably  no  harm  whatever  would  come  from  inserting 
the  nozzle  of  the  insufflation  apparatus  and  proceeding  with  the  insuffla- 
tion anesthesia  in  the  regular  way.  because  the  catheter  will  be  blown 
clear  by  the  insufflation  pressure  and  brought  out  liy  the  return  flow. 
The  reason  why  the  expiratory  current  does  not  clear  it  is  that  there  is 
so  much  room  for  expiratory  air  around  the  catheter  that  there  is  very 
little  pressure  on  the  secretion  in  the  catheter.  The  author  recently  in- 
sufflated a  patient  with  bilateral  laryngeal  paralysis.  He  put  in  an  extra 
tube  for  the  return-flow  but  found  it  quite  unnecessary,  for,  even  with 
the  tracheotomic  wound  closed  with  the  finger,  there  was  ample  return- 
flow  between  the  flaccid  cords  which  flapped  in  the  breeze  of  the  return- 
current.  He  had  feared  that  in  the  absence  of  the  inspiratory  abducting 
excursion  there  might  be  some  obstruction  in  the  larynx  and  the  tracheo- 
tomic wound  was  obstructed  witli  granulations.  For  the  introduction  of 
insufflation  tubes  the  side-opening  laryngoscope  (Fig.  1'))  has  some  ad- 
\'antages.  After  the  catheter  is  inserted,  the  laryngoscope  may  be  re- 
moved sideways  tlimugh  the  lateral  opening.  After  skill  in  direct  laryn- 
goscopy is  acquired,  the  slide  may  be  left  ot¥  entirely,  but  at  first  one  is 
apt  to  he  troubled  by  the  tongue  curling  in  and  obstructing  the  view. 
This  is  [irevented  by  passing  the  speculum  to  the  riglit  of  the  tongue,  thus 
lea\ing  the  tongue  on  the  closed  side  of  the  speculum.  The  author's  per- 
sonal preference  is  for  the  regular  laryngosco])e.  Fig.  14. 

^lention  is  made  above  of  deep  anesthesia.  ( )nce  the  knack  is  ac- 
(|uired  no  anesthetic  whatever,  general  or  local,  is  needed  to  expose  the 
larynx  in  any  patient ;  btit  to  the  beginner  it  simplifies  the  acquiring  of 
the  knack  of  direct  laryngoscopy  to  abolish  the  reflexes  of  vomiturition 
and  coughing,  and  to  abolish  entirely  the  antagonism  of  certain  muscles 
attached  to  the  hyoid  bone.  In  the  author's  clinic  an  anesthetic,  general 
or  local,  is  never  used  for  direct  laryngoscopy,  bronchoscopy  or  esophagos- 
copy  in  any  child  under  (i  years  of  age,  and  rarely  in  adults,  except  for 
a  few  special  procedures ;  but  for  insufflation  anesthesia,  the  jiatient  may 
as  well  be  jiut  comjiletely  under  by  the  open  method  as  only  partially. 
To  cocainize  the  larynx  for  the  insertion  of  an  insufflation  tube  to  help 
along  in  partial  anesthesia  is  an  utterly  needless  waste  of  lime. 


CHAPTER     V. 

Bronchospic  Oxygen  Insufflation. 

Broiichoscopic  oxygen  insiifllatiuit.  Some  experiments  made  upon 
the  clog  by  Dr.  Otto  C.  ("lauh,  with  the  assistance  of  the  author,  showed 
clearly  that  the  lunt;  which  ordinaril}'  collapses  when  the  pleural  cavity 
is  opened  may  he  intlated  with  oxygen,  deflated  or  held  ])artiallv  inflated, 
by  the  hronchoscojjist  at  the  command  of  the  surgeon.  Oxygen  can  be 
admitted  to  the  unoperated  lung  and  a  constant  return-flow  maintained 
so  that  the  \ilal  pulmonar\  hemic  changes  go  on  normally  and  pleural 
shock  is  also  lessened.  Fiu'thermore.  the  lung  on  the  ojjerated  side  can 
be  allowed  to  collajise  without  danger  to  the  patient,  thus  allowing  the 
surgeon  ample  room  for  work  with  the  hands  and  instriuuents  within  the 
thorax.  Again,  indejiendent  of  inilation  and  deflation  a  constant  supply 
of  oxygen  is  kejit  streaming  through  the  lungs  supplying  every  need,  as 
shown  by  the  ])ink  color  of  the  blood.  Tiie  usefulness  of  this  procedure 
so  far  as  thoracotomy  is  concerned  has  disappeared  since  the  method  of 
intratracheal  insufflation  anesthesia  has  been  introduced  by  Melzer  and 
.\ner  and  developed  by  Elsberg,  Janeway  and  others;  but  for  the  liron- 
choscopist,  the  bronchoscoi)ic  oxygen  insufllation  is  a  life-saving  pro- 
cedure always  at  immediate  command.  The  method  is  simple  and  is 
shown  .schematically  in  Fig.  63.  The  bronchoscope  preferably  of  small 
size  (  T  nmi.  for  adults,  4  mm.  for  children)  is  inserted  through  the  glot- 
tis, 'i'he  tube  from  the  oxygen  tank  is  attached  to  the  anesthesia-inlet 
of  the  bronchoscope  and  the  oxygen  turned  on  at  the  tank  \al\c  (V). 
There  is  no  danger  from  over-pressure  because  the  bronchoscope  is  open. 
The  operator's  thumb  (T)  must  never  be  placed  over  the  proximal  open- 
ing of  the  bronchoscope,  because  of  the  danger  of  over-jjressurc.  The 
fundamental  law  which  nuist  be  constantly  before  the  luind  is  that  of 
C'rile.  In  brief,  the  intra])ulmonary  pressure  must  not  exceed  the  capil- 
lary lilooil  pressure  or  the  compression  of  the  capillaries  and  consequent 
ischemia  will  prove  fatal.  This  cannot  occur  if  the  orifice  of  the  broncho- 
scope is   open   because  there   is  such  an   ample   return-flow   through  the 


74 


BRONCHOSCOPIC  OXYCEN    INSUFFLATION. 


lironclioscopic  lumen  that  absolute  safety  from  over-pressure  is  assured. 
Of  course  tlie  lungs  cannot  be  thus  forcibly  inflated,  and  the  usual  arm- 
motion  artificial  respiration  must  be  used  in  addition  in  this  form  of 
bronchoscopic  oxygen  insulHation.  But  the  bronchoscope  establishes  an 
artificial  airway  which  is  stronglv  charged  with  oxygen  and  which  can- 
not be  obstructed  by  dropping  back  of  the  tongue.  A  small  esophago- 
scope  may  be  used  instead  of  the  bronchoscope,  the  oxygen  tubing  from 
the  tank  being  attached  to  the  drainage  outlet.  The  drainage  canal  will 
thus  carry  oxygen  right  down  to  the  bifurcation.  Nitrite  of  amyl  pearls 
should  be  carried  in  every  bronchoscope  box  as  amyl  nitrite  is  the  most 


Fig.  63.  Schema  showing  bronchoscopic  oxygen  insufflation.  The  broncho- 
scope is  in  the  trachea.  Oxygen  enters  by  the  small  branch  tube  and  is  taken  in 
by  natural  or  artificial  respiratory  movements.  If  an  esophagoscope  is  used  the 
oxygen  can  be  blown  in  through  the  auxilliary  drainage  canal  to  the  distal  end  of 
the  esophagoscope.  This  is  safe.  The  lungs  could  be  inflated  by  momentarily  clos- 
ing the  escape  by  putting  the  thumb,  T,  over  the  proximal  end  of  the  bronchoscope 
alternately  releasing  it,  but  this  would  be  a  very  dangerous  procedure  unless  over- 
pressure be  carefully  guarded  against.  If  preferred,  the  independent  drainage  tube 
used  for  aspiration  can  be  inserted  through  the  bronchoscope. 


promptly  available  stimulant  in  such  cases.  A  pearl  may  be  broken  in  a 
tuft  of  cotton  and  thrown,  cotton  and  all,  into  the  wash  bottle  of  the 
oxygen  tank.  There  is  only  from  two  to  three  minutes  between  the 
respiratory  and  the  cardiac  arrest,  so  that  in  cases  of  serious  respiratory 
arrest  in  which  the  operator  does  not  feel  confidence  in  the  promptness 
and  certainty  of  his  bronchoscopic  introductory  technic,  it  is  far  safer  to 
do  an  emergency  tracheotomy,  dilate  the  wound,  crack  an  amyl  nitrite 
pearl  in  cotton,  hold  the  cotton  over  the  wound  and  blow  oxygen  past 
the  cotton  into  the  trachea,  while  an  assistant  performs  artificial  respir- 
ation.   In  this  case  it  is  necessary  for  the  operator  to  stand  at  the  head- 


BKOXCnOSCOI'IC  OXVGEX    INSUFFLATION.  75 

end  of  the  table  facing  the  patient's  feet  so  as  not  to  interfere  with  the 
arm  movements.  The  great  drawback  to  machines  for  artificial  respira- 
tion using  masks  is  that  the  vocal  cords,  because  of  their  shape,  else- 
were  shown,  have  a  natural  tendency  to  be  forced  shut  l>y  the  in-going 
blast,  and  because  of  the  pharyngo-laryngo-faucial  danger-zone.  The 
latter  can  be  overcome  to  a  great  extent,  in  using  the  mask,  but  the  laryn- 
geal closure  cannot.  I'oth  danger-zones  are  very  much  increased  by 
the  flaccid  condition  of  the  parts  in  impending  death  from  res- 
piratory arrest;  but  this  same  flaccidity  is  a  great  advantage  in  the  peroral 
insertion  of  a  bronchoscope  because  of  the  associated  total  absence  of 
spasm.  When  a  tube  is  inserted  into  the  trachea  for  the  insufflation  of 
oxygen,  conditions  are  ideal  because  there  is  no  obstruction  to  the  return- 
flow  such  as  there  is  to  the  in-flow.  This  does  not  mean  that  there  is  no 
danger  from  excessive  plus  pressure,  which  must  be  carefully  guarded 
against :  nor  should  any  of  the  foregoing  be  taken  as  a  criticism  of  ma- 
chines of  pulmotor  type.  Such  machines  are  life-savers  of  the  greatest 
value,  because  they  can  be  used  by  anyone  with  but  little  instruction, 
without  the  training  necessary  for  the  insertion  of  an  intratracheal  tube. 
Vet  this  does  not  alter  the  fact  that  intratracheal  oxygen  insufflation  is 
ideal  anrl  everv'one  who  has  to  deal  with  resjiiratory  arrest  should  be 
taught  the  technic  of  laryngeal  exposure  for  intratracheal  insufllation, 
because  the  visual  method  is  the  only  one  which  is  certain  under  all  cc)n- 
ditions.  For  instance,  the  author,  in  one  of  our  hospitals  was  called  into 
an  adjoining  operating  room,  where  a  surgeon  and  his  assistants  lia<l 
tried  forced  mask  resi>iratian,  then  tracheal  intubation  by  blind  method. 
The  mask  method  had  given  relief  for  a  time  but  the  patient  had  grad- 
ually become  unconscious  and  cyanotic.  The  surgeon's  assistant  was  an 
expert  at  blind  intubation  and  could  not  understand  his  inability  to  in- 
tubate in  this  instance.  The  author  took  with  him  his  larxngoscope  and 
exposure  of  tlu'  larynx  revealed  occlusion  with  a  grayish  mass  which 
proved  to  be  meat.  Intratracheal  oxygen  insufflation  after  removal  of 
the  meat  kept  the  man  alive  until  he  could  be  trusted  to  do  his  own 
breathing.  The  man  was  in  a  state  of  profound  alcoholism  when  brought 
in  from  the  gutter  in  front  of  the  hospital  and  doubtless  the  meat  had 
been  vomited.  That  the  respirator  machine  had  forced  the  meat  farther 
into  the  larynx  is  no  criticism  against  the  machine  for  the  general  run  of 
cases;  and  the  surgeon,  had  a  lar\ngoscopist  not  been  available,  would 
have  done  a  tracheotomy,  with,  doubtless,  an  equally  happy  result;  yet 
this  does  not  lessen  the  force  of  the  lesson  that  in  cases  of  respiratory 
arrest  the  fundamental  rec|uirement  is  to  see  that  the  larynx  is  free  from 
obstruction.  If  this  laryngeal  inspection  required  special  aptitude  the 
author  would  not   feel  like  urging  it  so  strongly;  but  anyone  capable  of 


76  BKoxciuisconc  oxyckn  insufflation. 

dealing  with  rfS])iratory  arrest  at  all  can  b\  practice  acquire  the  ability 
to  inspect  any  case,  and  the  easiest  of  all  cases  is  the  one  of  respiratory 
arrest,  because  of  the  total  absence  of  spasm.  Such  a  patient  is  just  like 
a  cadaver  and  practice  upon  the  cadaver  is  excellent  training  for  this 
work.  There  is  the  same  insertion  of  the  direct  laryngoscope  and  the 
raising  and  suspension  of  the  limp  head  on  the  beak  of  the  spatular  end. 
the  operator  being  in  the  standing  position  for  a  patient  on  a  table,  and 
kneeling  on  the  floor,  for  a  patient  recumbent  on  the  floor.  Of  course 
the  cadaverous  limpness  and  ashv  blue-blackness  of  the  mucosa  does  not 
conduce  to  the  operator's  equanimity,  but  the  confidence  in  his  ability 
promptly  to  expose  and  inspect  the  larynx  and  to  catheterize  the  trachea, 
which  comes  with  practice,  will  meet  the  emergency.  Life-saving  et^c- 
iency  demands  that  every  well-equipped  hospital  shall  have  at  least  one 
man  trained  for  this  emergency  work. 


CHAPTER     VI. 

Position  of  the  Patient  for  Peroral  Endoscopy. 

General  considerations.  The  position  of  the  patient  varies  with  the 
age  of  the  patient,  the  part  to  be  examined,  the  purpose  of  the  examina- 
tion and  especially  with  the  personal  equation  of  the  operator.  J'rac- 
tically  all  jirocedurcs  nf  the  laryngologist  other  than  endoscopy  are  done 
"face  to  face"  with  the  patient.  When  the  patient  is  dorsally  recumbent 
nil  the  interior  anatomy  seems  strangely  unfamiliar;  and  all  the  more  so 
liecause  the  book  illustrations,  which  uncnnsciousl_\-  form  the  basis  of 
mental  [liclures.  have  never  sliown  the  parts  in  this  position.  Jt  is  the 
effort  of  this  l>ook  to  supply  this  need  as  to  illustrations,  and  to  en- 
courage otliers  to  practice  diligcntlv  to  overcome  tlie  ])reference  for  the 
sitting  position  and  for  the  exceedingly  awkward  lateral  recumbent  po- 
sition. Once  the  habit  of  working  in  the  recumbent  position  has  been 
ac(|uired,  better  work  can  Ije  done  in  both  adults  and  children  because  of 
the  greater  ease  with  which  secretions  and  foreign  bodies  are  removed 
unopposed  by  gravitx'.  In  children  we  have  the  added  reason  of  greater 
controllability:  not  but  that  a  child  can  be  lu-ld  as  is  usu;d  (  ihough  not 
necessarily  desirable)  for  laryngeal  intubation;  but  harm  may  l)e  done 
if  the  child  is  not  perfectly  controlled.  There  is  no  upright  control  that 
comi)arcs  with  the  fixity  of  the  child  held  down  on  a  well  padded  fiat 
table  top.  In  dyspneic  cases,  should  tracheotomy  become  necessary, 
the  bronchoscope  can  be  inserted  for  breathing,  and  tlien  the  child  is 
all   ready  upon  the  t;il)le   for  tracheotomy. 

/;;  children  from  every  point  of  view,  therefore,  it  is  desirable,  for 
e\ery  form  of  peroral  endoscopy,  to  use  the  dorsally  recumbent  position, 
which,  if  correctly  posed,  is  much  easier  for  both  patient  and  o])eralor 
than  the  lateral. 

The  lateral  position  lor  bronchoscopy  and  esophagoscopw  in  cither 
adults  or  children,  has  found  but  little  favor  in  America.  Its  onK-  real 
advantage  is  the  facility  with  \\bicli  secretions  (lr;iin  Irum  the  lowenuost 


78  POSITION   OF   THE  PATIENT  FOR  PERORAL   ENDOSCOPY. 

corner  of  the  mouth.  This  can  be  accomphshed  almost  as  well  in  the 
dorsal  position  with  a  wick  of  gauze  hanging  out  over  from  the  pharynx, 
the  outer  end  the  longer.  If  secretions  are  too  thick  to  drain  by  capil- 
larity, the  gauze  is  frequently  replaced  by  a  fresh  piece.  An  aspirating 
drainage  tube  of  metal  (Fig.  24)  connected  with  the  author's  esophagos- 
copic  aspirator  (Fig.  23)  is  hooked  into  the  lowermost  portion  of  the 
patient's  mouth  in  bronchoscopy.  This  rids  the  mouth  of  secretions 
while  the  patient  is  in  the  dorsal  position.  One  thing  that  has  led  some 
endoscopists  to  think  that  the  lateral  position  is  easier  is  that  in  the  lat- 
eral position  the  operator  does  not  so  readily  make  the  mistake  of  ex- 
tending the  cervical  spine  instead  of  extending  simply  the  head  upon 
the  atlas.  If  the  operator  should  stand  instead  of  crouch,  in  doing  a 
peroral  endoscopy  upon  a  patient  in  the  dorsal  position,  he  would  have 
the  correct  head-position  of  the  patient. 

In  foreign-bodx  cases,  whether  in  adults  or  children,  no  matter  where 
the  foreign  body  is  located  (even  in  the  fauces  or  nasopharynx),  the 
patient  should  always  be  recumbent,  never  erect,  because  in  the  erect 
position  gravity  works  against  the  operator,  and  the  foreign  body  may 
reach  a  deeper  point  in  the  air  passages  than  it  would  in  the  recumbent 
position.  This  is  particularlv  true  of  foreign  bodies  in  the  larynx  and 
pharynx,  which  should  never  be  touched  unless  the  patient  is  in  the 
Trendelenberg  position.  Quite  a  large  proportion  of  the  foreign  bodies 
in  the  bronchi  that  have  been  sent  in  to  the  author,  were  originally  in  the 
larynx,  pharjnx.  mouth  or  nasopharynx  and  fell  down  when  displaced 
by  the  attempts  of  the  operator,  who  first  saw  the  case,  to  remove  the 
intruder  with  the  patient  in  the  sitting  position. 

in  adults.  For  the  diagnosis  of  laryngeal  disease  and  for  the  re- 
moval of  specimens,  or  of  entire  growths,  by  direct  larv^ngoscopy  under 
local  anesthesia  the  sitting  position  of  both  patient  and  operator  is  the 
best.  In  the  few  cases  in  which  a  general  anesthetic  is  needed  for  direct 
laryngoscopy  the  recumbent  position  is  obligatory  as  wel!  as  advantag- 
eous. 

For  bronchoscopy  for  diagnosis,  which  is  practicallv  always  done 
under  local  anesthesia,  the  adult  patient  may  be  sitting.  If  there  is  much 
Secretion  to  be  removed  this  is  somewhat  of  a  disadvantage,  but  with  an 
active  cough-reflex  the  secretion  may  be  gotten  rid  of  without  difficulty, 
even  in  bronchiectatic  and  pulmonary  abscess  cases.  The  author's  per- 
sonal preference  in  such  cases  is  for  recumbency.  For  bronchoscopy  for 
foreign  bodies  in  adults,  as  before  mentioned,  the  recumbent  position  is 
always  best. 

For  esophagoscopy  for  diagnosis  and  treatment,  with  or  without 
anesthesia,  the  author's  preference  is  for  the  recumbent  position.     It  has 


POSITION-  OF  THE  PATIENT  EOR  PERORAI,  ENDOSCOPY. 


79 


great  advantages  in  dealing  without  interrui»tion  with  the  secretions  and 
food  debris,  so  abundant  in  many  cases,  and  the  patient  is  much  more 
controllable.  When  a  start  is  made  it  is  a  waste  of  time  to  withdraw 
the  tube  because  the  patient  has  slid  off  the  stool  or  is  strangling  with 
secretions  which  have  overflowed  into  his  larynx. 

General  prineiples  of  all  positions.  The  general  principles  of  all 
useful  positions  are  the  same.  The  author  was  the  first  to  call  the  atten- 
tion of  endoscopists  to  the  fact  that  the  trachea  and  esophagus  are  not 


Fig.  64.  Schematic  ilhistrauon  of  normal  position  of  the  intra-thoracic  trachea, 
and  also  of  the  entire  trachea  when  the  patient  is  in  the  correct  position  for  peroral 
bronchoscopy,  such  as  the  original  Kirstein  position,  or  that  shown  in  Fig.  70. 
When  the  head  is  thrown  backward  (as  in  the  usual  or  in  the  Rose  position)  the 
anterior  convexity  of  the  cervical  spine  is  transmitted  to  the  trachea  of  which  the 
axis  is  thus  deviated.  The  correct  position  is  produced  in  the  recumbent  patient  by 
raising  the  head.  The  anterior  deviation  of  the  lower  third  of  the  esopliagus  shows 
the  anatomical  basis  for  tlic  autlior's  "high-low''  position  for  esophagoscopy.  (Figs. 
140  to  152). 


perpendicular.  Their  long  axis  passes  backward  as  well  as  downward 
following  the  general  direction  of  the  thoracic  spine  (Fig.  (il).  There- 
fore, if  we  throw  the  patient's  head  backwards  we  cause  an  anterior  con- 
vexity of  the  cervical  spine,  and  with  it  the  esophagus  and  trachea,  as 
shown  in  the  radiograph.  Fig.  GG.  The  Rose  position  and  the  usual  in- 
correctly ajijilied  extended  position  make  this  extension  tbroiighniu  ihr 
entire  cervical  spine  as  shown   in  I'ig.  GG.  rendering  peroral   endoscopv 


so 


POSITION  OF  THE    PATIKXT  FOR    PliRORAL  EXDOSCOPV. 


Fig.  05.  (orrect  positiim  ol  the  cervical  spine  for  esopluiguscopy  ami  bron- 
choscopy. (Illustration  reproduced  from  author's  article,  Jour.  A.  M.  A.,  Sept. 
25.  igog). 


Fig.  66.  Curved  position  of  the  cervical  spine,  with  anterior  convexity,  in  the 
Rose  position,  rendering  esophagoscopy  and  bronchoscopy  difficult  or  impossible. 
The  devious  course  of  the  pharynx,  laryn.x  and  trachea  are  plainly  visible.  The 
extension  is  incorrectly  imparted  to  the  whole  cervical  spine  instead  of  only  to  the 
occipito-atloid  joint.  This  is  the  usual  and  very  faulty  conception  of  the  extended 
position.  (Illustration  reproduced  from  author's  article.  Jnur.  A.  M.  A..  Sept.  23, 
1909). 


POSITION  (I'"  THE  PATIENT  FOR  PERORAI,  ENDOSCOPY. 


81 


extremely  dilhcull  or  impossible,  as  demonstrated  by  tbe  author  years 
ago  (Bib.  23(1).  Jn  the  correctly  posed  extended  position  the  e.xten.sion 
is  at  the  occipito-atloid  joint,  and  the  cervical  spine  is  strongly  inclined 
forward  (upward  in  the  recumbent  position  as  shown  in  Fig.  (!.")).  If 
it  is  not  desired  to  extend  the  head  the  cervical  spine  nevertheless  remains 


Fig.  67.  Lateral  radiograph  of  a  cliiUl  ol  4  >i.'.ir.>,  shuuiiij;  llic  normal  direc- 
tion of  the  trachea.  \  pale  streak  is  seen  extending  backward  as  well  as  down- 
ward, ending  at  the  foreign  body  in  the  right  bronchus.  There  is  a  narrowing  of 
this  streak  at  the  bifurcation,  representing  a  llatlening  in  mi  before  backwards. 
Compare  schema,  Fig.  64. 


the  s;une.  W  JK-tlur  the  head  is  flexed  or  extended  or  kenl  niidwiiy.  the 
fundament.-d  [irinciple  of  all  positions  is  the  aiiteiidr  placing  of  the 
cervical  spine  (I'ig.  '>'"i). 

Sitliii(/  l^osituni  of  the  adult  l^tiliriit  for  direct  lary)i(iosco['y.  The 
orii,'inal  jiosition  of  Kirstein  descrii)ed  by  him  2U  years  ago,  when  he 
originated   direct   laryngoscopy,   contained   the   essentials   of   the   correct 


82 


POSITION   OF  TirK  PATIKNT  FOR  PERORAL   ENDOSCOPY. 


position  ancl  has  been  but  sHghtl\-  improxed  upon.  As  it  seems  to  have 
been  forgotten,  an  illustration  of  it  taken  from  an  old  instrument  cata- 
logue is  here  reproduced  (Fig.  (iS). 

Alouret  (Eiib.  -lUU  )  arrives  at  the  necessary  forward  position  of  the 
head  by  having  the  patient  sit  astride  of  a  narrow  backed  chair  facing 
backwards  with  the  pelvis  as  far  toward  tiie  front  edge  of  the  chair  as 
possible,  the  pehis  being  tilted  forward  toward  the  operator  who  is  back 
of  the  chair  as  will  be  seen  by  referring  to  Fig.  (i!i. 

The  author's  position  for  direct  laryngoscopy  upon  the  sitting  patient 
under  local  anesthesia  will  Ije  understood  by  reference  to  Fig.  70.  This 
position  is  also  u.sed  occasionally  for  diagnostic  bronchoscopies,  never 
for  esophagoscopies. 


Fig.  68.  Kirstein  poMtiuii  hIikIi  cmuains  the  essentials  of  the  best  position  for 
direct  laryngoscopy  on  the  sitting  patient.  The  extreme  anterior  displacement  of 
the  cervical  spine  with  extension  only  at  the  occipito-atloid  joint  and  avoidance  of 
instrumental  counterpressure  on  the  upper  teeth  are  fundamental.  This  illustration 
is  reproduced  from  an  old  instrument  catalogue.     (1895)   Bib.  323. 


The  patient  should  be  seated  on  a  stool  about  :')ii  cm.  high.  The 
operator  sits  upon  a  stool  rather  lower  than  shown  in  the  illustration. 
The  second  assistant  sits  on  a  high  stool  back  of  the  patient  keeping  the 
patient's  head  far  forward  toward  the  operator,  extended  or  flexed  as 
desired,  usually  extended  as  shown,  but  always  forward.  The  assistant's 
knee  at  the  back  of  the  ])atient  prevents  the  ])atient  moving  liackward, 
and.  most  imjiortant.  ])revents  the  patient  arching  his  spine  backward. 
This  assistant's  right  index-finger  is  used  when  necessary  for  making 
counterpressure  externally  by  pulling  the  thyroid  cartilage  backward. 
The  operator's  knee  against  the  patient's  knee  holds  back  the  patient's 
hips.      In   exposing   the   larynx    by    direct   laryngoscopy   it   is   absolurcl_\- 


POSITION   01*   THE  PATir.XT   I"OR   PERORAL    ENDOSCOPY. 


83 


essential  for  prompt  work  and  especially  for  prompt  recognition  of 
landmarks  that  the  head  he  held  exactly  in  the  anteroposterior  vertical 
plane.  In  other  words,  neither  the  cervical  spine  nor  the  head  should 
he  permitted  to  rotate.  The  head  may  be  in  any  position  desired  as  to 
fle.xion  or  extension,  but  the  fundamental  instruction  to  the  assistant  who 
holds  the  head  should  be:  "Prevent  rotation  of  the  head."' 


Fig.  Cx).  Position  of  Mourct.  This  lias  llic  :irI\aiitaKc  tliat  tlic  patient's  body 
cannot  slide  forward  toward  tlic  operator  wlicn  the  head  is  pulled  forward.  Prof. 
Mourct  demonstrated  that  the  position  of  the  pelvis  and  dorsal  spine  arc  important. 


Keciimhci'i  f>ositwn  for  direct  laryntioxcopy,  hroiiclioscof'y  and  csof>li- 
agoscopy  in  adult  patients.  For  the  last  eight  years  the  author  has 
used  the  IJoyce  position  for  bronchoscopv  and  esophagosco])y  and  has 
found  it  to  fulfill  e\ery  reijuirement.  In  the  few  adult  ])atients  rec|uiring 
general  anesthesia  for  direct  laryngoscopv  it  is  also  used.  .\  full  de- 
scription written  h\  I)r.  i'.iiyce  is  given  in  the  earlier  \iilunic.  (  llih.  'i*>'K 
1007.)  Essentially  the  ])osition  (Fig.  72)  consists  in  having  the  pa- 
tient's head  and  ujjper  jiart  of  his  shoulders  out  in  the  air  supjinrtcd  by 


84 


POSITION  OF  THE  PATIENT  FOR  PERORAL  ENDOSCOPY. 


the  second  assistant's  left  hand,  which  in  turn  is  supported  on  the  as- 
sistant's left  knee,  the  left  foot  being  upon  a  stool  whose  top  is  about  (52 
cm.  below  the  top  of  the  table.  All  the  extension  and  raising  of  the  pa- 
tient's head  is  done  with  the  left  hand  of  the  assistant  whose  thumb  is 
on  the  patient's  forehead,  the  fingers  being  under  the  occiput.  The  mo- 
tion is  as  if  to  tnclc  the  forehead  back,  down  and  under,  while  at  the 


Fig.  70.  Showing;  the  author's  position  of  the  operator,  patient  and  assistant 
for  direct  laryngoscopy  on  adult  patients  under  local  anesthesia.  The  sitting  posi- 
tion of  the  operator  renders  laryngeal  exposure  easy  for  patient  and  operator; 
whereas  the  usual  standing  position  of  the  operator  throws  the  patient  into  a  pos- 
ture that  renders  laryngeal  exposure  difficult  hesides  throwing  the  trachea  out  of 
line     The  author  prefers  a  lower  stool  as  shown  in  Fig.  77. 


same  time  the  neck,  chin  and  whole  head  arc  raised.  The  right  hand 
is  passed  under  to  the  far  side  (left)  of  the  patient's  mouth,  the  right 
index  carrying  the  bite  block.  The  right  arm,  however,  usually  car- 
ries but  little  weight,  most  of  the  extension  and  the  very  important 
prevention  of  rotation  being  done  by  the  left  hand.  If  the  operator  and 
assistant  work  together   frequently  they  can   do  bronchoscopies  without 


POSITION  01'  THE  PATIENT  FOR  Pl'.RORAE  ENDOSCOPY. 


85 


loss  of  time  and  with  a  precision  tliat  cannot  lie  cc|iialle<l  by  an\-  other 
mcliiod.  Tliis  position  has  nothing  to  do  with  the  kind  of  instrument 
used.  There  is  no  instrument  made  for  bronchoscoiiy  or  esophagoscopy 
that  will  do  away  with  the  necessity  for  a  correct  [losition  of  the  patient 
t(jr  liest  results  in  <|uickness  and  precision.  With  the  patient  recumbent 
on  an  operating  table  of  the  ordinary  height  the  direct  laryngoscopist 
should  sit  on  a  stool  such  as  the  anesthetist  uses.  For  bronchosco])y 
(recumbent  position),  especially  after  the  bronchoscope  has  been  in- 
troduced, a  lower  stool  is  often  re(|uired  unless  the  posterior  branches 
are  being  explored.  For  the  middle  lobe  bronchus  it  is  necessary  for  the 
operator  to  sit  on  a  footstool.  In  beginning  an  esophagoscopy  the 
operator   stands.      Later  he  sits  on  a  low   stool   for  the   lower  third  of 


Fig.  71.  Child  with  liiuli  ihirs;il  liilicrculosis  at  llu-  I'itlsljiiruh  1  ln-,|iit;il  for 
Children.  The  author  maile  a  direct  laryiinoscoiiic  examination,  without  changing 
tlie  child's  position  or  removing  the  apparatus,  by  standing' on  the  left  side  of  the 
bed.  as  demonstrated  by  Richard  H.  Johnston,  Fig.  11.  This  child  had  a  flabby  up- 
per laryn.ycal  orifice  causing  an  inspiratory  stridor. 


the  esophagus.  The  neces.sity  for  stools  of  different  heights  for  the 
operator  is  lessened  in  special  tables  l)y  the  elevation  or  lowering  of 
the  entire  table,  patient  and  all.  by  sjiecial  mechanism.  The  raising  and 
lowering  of  the  head  and  tlie  lateral  movements  will  be  considered  wlien 
writing  of  the  introduction  of  the  instruments  and  of  \ariiuis  i)rocediues. 
Moslier  (  Hill.  .'IHO  1  demonstralcd  ilie  \aluc  of  tlexion  of  the  head  m 
the  recumbent  i)ositi(jn  for  direct  laryngoscopy  by  a  laterally  rotating 
speculum.  Richard  H.  Johnston  (liib.  •iSC )  demonstrated  the  usefidness 
of  flcxiufi  the  head  in  certain  cases  for  direct  laryngoscopy  on  the  re- 
cumbent patient,  j/utting  a  small  pillow  under  the  ])atients'  head,  the 
ni)erator  standing  to  the  left  side  of  the  jiatient.  This  flexed  position 
is  particularly  advantageous  where  the  operator  is  without  a  regularly 


8G 


POSITION   OF   THE  PATIENT   FOR  PERORAL   ENDOSCOPY. 


trained  assistant  with  whom  he  is  in  the  habit  of  working,  because  any- 
one can  hold  the  head  on  the  pillow.  The  position  is  not  adapted  to 
bronchoscopy,  though  Johnston  uses  it  to  start  the  tube,  and  then  the 
head  of  the  patient  is  brought  into  the  Boyce  position.  This  change  re- 
quires a  well-trained  assistant  and  great  care  to  prevent  any  traumatism 
to  the  trachea  in  making  the  change.  I  have  found  the  Johnston  posi- 
tion exceedingly  useful  in  disease  of  the  cervical  spine  where  the  chil- 
dren were  fixed  in  an  apparatus  which  I  did  not  need  to  disturb  to  get 
an  excellent  view  of  the  larynx  (Fig.  71). 


Fig.  "/i.  Position  of  patient  and  second  assistant  in  bronclioscoiiy  and  esopli- 
agoscopy  (Boyce  position).  Tlie  left  hand  is  supported  on  the  left  knee,  the 
left  foot  being  elevated  on  a  stool.  The  right  forearm  is  under  the  patient's  neck, 
the  right  index  carrying  the  bite  block.  Tlie  right  forearm  carries  little  weight, 
most  of  the  e-^;tcnsion  being  done  with  the  left  hand. 


Position  of  tlic  patient.  Children.  Children  are  always  best  ex- 
amined in  the  recumbent  position,  and  there  being  no  anesthetic,  general 
or  local,  it  is  usually  rec|uired  that  they  be  held.  The  method  of  doing 
this  is  as  follows :  The  child  is  placed  in  the  correct  position  on  the 
table  with  reference  to  the  end  of  the  table  so  that  the  head  will  be  out 
in  the  air  for  the  second  assistant  to  hold.  P.nth  knees  are  held  down 
by  a  nurse  who  stands  at  the  foot  of  the  tabic.  Both  hands  are  held 
down,  one  at  each  side  of  the  [latient  either  by  a  nurse  or  by  a  physician 


POSITION   OF   THE  PATIKNT   FOR  PERORAI,  ENDOSCOPY. 


87 


who  is  watching  the  puke.  Tliis  same  person  can  also  prevent  the  cliild 
from  throwing  the  chest  upward,  as  some  children  do.  I'pward  move- 
ment of  the  chest  is  to  be  avoided  because  it  has  relatively  the  same 
effect  as  depressing  the  iiead.  The  position  of  each  of  the  three  persons 
required  will  be  understood  by  reference  to  Fig.  7;>. 

This  holding  is  only   required   with  a   terrified   child   es])ecially   the 
first  few  times.     Most  children  soon   lose  all   fear  and   where  necessarv 


Fifj,  73.  Position  of  patient,  assistant  and  two  nurses  to  hold  a  child  for  di- 
rect laryngoscopy,  bronchoscopy  and  esophagoscopy.  The  assistant  holds  the  head 
in  the  Boyce  position.  The  nurse  on  the  patient's  right  holds  the  patient's  wrists 
down  on  the  table.  The  nurse  on  the  left  side  of  the  patient  holds  down  the  pa- 
tient's knees.  The  operator  is  holding  the  direct  laryngoscope.  As  soon  as  it  is 
introduced  the  patient's  head  is  raised  al)ove  the  level  of  the  table. 


to  have  repealed  endoscopies  they  soon  learn  that  the  procedure  is  not 
painful  and  submit  without  being  held. 

The  author  often  has  children  of  '■>  and  1  years  lie  down  on  the 
table,  open  their  mouths  and  wait  for  a  speculum  to  be  inserted  and 
papillomata  removed,  time  after  time,  without  any  holding  whatever  ex- 
cept the  supjiort  of  the  head  iiy  the  second  assistant. 

As  in  the  sitting  position  of  the  patient,  or.e  of  the  most  inipuriant 
things  is  strongly  to  im|)ress  upon  the  mind  of  the  assistant  who  holds 
the  head  that  nc\er,  under  any  circumstances  is  he  tn  iiermit  the  head  tn 


88 


POSITION'  OF  THE  PATIENT  FOR  PERORAL  ENDOSCOPY. 


rotate.  Tlie  head  must  yield  freely  and  follow  the  operator  in  the 
lateral  or  vertical  plane,  but  it  must  never  rotate  on  the  axial  bone  or 
the  cervical  spine.  Such  rotation  distorts  the  endo-anatomical  land- 
marks and  renders  difficult  the  otherwise  easy  task  of  tinding  the  larynx 
or  ])yriform  sinuses,  as  the  case  may  be. 


'"'U  7.3  \-  -Author's  position  of  the  patient  for  tlie  removal  of  foreign  hodies 
from  the  larynx  or  from  any  of  the  upper  air  or  food  passages.  If  dislodged,  the 
intnidir  will  not  he  aided  by  gravity  to  reacli  a  deeper  lodgement. 


For  the  use  of  the  esophageal  speculum  the  patient  may  be  placed 
cither  in  the  sitting  position  as  for  laryngoscopy  (Fig.  70),  or  in  the 
recumbent  positinn  as  for  starting  the  introduction  of  the  esoi)hagoscope 
f  Fig.  ";'■>).    The  author  prefers  the  latter. 


CHAPTER     VII. 

Direct  Laryngoscopy. 

General  considerations.  Enthusiastic  as  he  is  in  regard  to  the  use- 
fulness of  the  direct  method,  for  both  diagnosis  and  treatment,  the  au- 
thor wishes  to  state  at  the  outset  that  he  examines  every  case  by  the 
indirect  method  first,  if  it  is  possible  to  make  such  an  examination.  The 
exceptions  arc  in  infants  and  small  children  who  cannot  be  examined  by 
the  mirror  imless  they  are  under  a  general  anesthetic,  and  also  an  occa- 
sional case  of  great  nrgcncy  in  adults.  The  field  of  llic  two  methods  is 
entirely  different.  The  presence  of  the  tube  excites  reflexes  which  inter- 
fere with  the  detection  of  slight  \ariations  in  mobility,  unless  anesthesia 
is  profouiKJ,  and  then  onlv  resi)iratorv  movements  could  he  ])ri.-scnl. 
Of  course,  great  facility  enables  one  to  overcome  this  drawback  to  some 
extent  and  also  the  disadvantage  which  comes  from  the  increased  ten- 
dency to  distortion,  owing  to  very  slight  lateral  displacement  of  the  tube 
or  the  tissues.  Xe\ertheless  it  may  be  stated  as  a  general  rule  that  the 
direct  method  is  not  adapted  to  accurate  determination  of  motile  detects. 
One  great  advantage  of  the  use  of  both  methods  in  the  same  case,  where- 
cver  ])ossible,  is  that  the  view-point  is  entirely  different,  the  one  supple- 
menting the  other.  The  view  obtained  in  the  mirror,  ]\1,  Fig.  7-i,  is  as  if 
the  observer's  eye  were  at  the  vertex  of  the  patient's  head,  represented 
by  A  In  contrast  to  this,  in  the  direct  examination,  the  observer's  eye 
is  at  D.  W  ere  the  tissues  to  be  examined  a  plane  horizontal  surface,  there 
would  be  practically  no  difference,  but  in  examining  a  more  or  less  funnel- 
shaped  cavity,  like  the  larynx,  the  difference  of  the  point  of  view  become? 
verv  great,  especially  as  to  the  position  of  growths  down  within  the  funnei 
(as  for  instance  at  the  cord)  in  their  relation  to  the  uiijar  l.nyngeal  orifice. 
It  will  be  easily  understood  from  the  schema.  Fig.  71,  that  growths  on 
the  cords  always  give  the  appearance  of  Ijeing  located  nearer  the  pos- 
terior commissure  than  they  actually  are,  and  very  much  nearer  than 
thev  seem  to  be  b\'  the  direct   method.     Another  great  difTercncc  is  that 


!)0 


dirf.ct  laryngoscopy. 


the  direct  method  gives  a  better  view  of  the  anterior  aspect  of  the  pos- 
terior wall,  H,  of  the  larynx  because  the  visual  axis  is  more  nearly  per- 
pendicular to  the  surface.  The  indirect  view  of  the  posterior  surface  of 
the  posterior  wall  can,  of  course,  be  very  much  increased  by  von  Eicken's 
method  of  drawing  the  larynx  forward  so  as  to  see  the  hypopharynx  by 


D 


A 


Fig.  74. — Schema  illustrating  the  difference  between  the  views  obtained  by 
direct  and  by  indirect  laryngoscopy.  The  observer's  visual  axis  at  E,  looking 
into  the  mirror,  M,  pets  an  image  as  if  he  were  looking  from  a  point  back  of  the 
patient's  head,  .\.  Looking  thus,  the  image  of  a  growth  on  the  cord  at  C  is 
seen  just  over  the  top  of  the  arytenoid  eminence  to  which  it  seetns  very  close, 
because  almost  in  line.  This  schema  also  shows  how  the  anterior  surface  of  the 
po-Sterior  wall  at  H,  is  in  the  line  of  vision  by  direct  laryngoscopy  and  more  or 
less  hidden  in  some  cases  during  indirect  examination,  by  an  apparent  forward 
overhan.g  of  ihc  liorder  of  the  arytenoid  eminence  and  the  aryepiglottic  fold. 

hypopharyngoscopy.  The  hypopharynx  can  also  be  viewed  by  putting 
the  direct  laryngoscope  down  back  of  the  posterior  wall  at  H,  and  draw- 
ing the  entire  larvnx  forward.  It  is  also  worthy  of  note  that  the  an- 
terior surface  of  the  posterior  wall  can  often  be  observed  l>y  the  Killian 
method  of  using  the  laryngeal  mirror  with  the  i)atient  standing  and  the 


DIRIXT  LARYNGOSCOPY.  91 

observer  kneeling,  the  patients'  head  being  bent  forward  and  downward 
toward  the  observer. 

It  may  seem  strange  at  this  late  day  for  anyone  to  advocate  the 
more  frequent  use  of  the  indirect,  mirror  larj'ngoscopy,  and  yet  it  is 
neglected  in  routine  surgical  work.  The  author  believes  that  general 
anesthesia  for  any  purpose  should  always  be  preceded  by  a  preliminary 
examination  of  the  laryn.x  by  the  indirect  method,  provided  the  patient 
can  be  so  examined  ;  and  this  statement  applies  to  any  and  all  cases,  sur- 
gical or  otherwise,  for  which  an  anesthetic  is  desired  to  be  given.  It  is 
incomprehensible  why  it  is  so  generally  neglected  before  goitre  opera- 
tions. If  this  rule  were  observed,  there  would  not  be  as  many  myster- 
ious deaths  on  the  table  and  shortly  after  operation  to  be  accounted  for 
by  such  highly  hxpothetical  diagnoses  as  hyperthymization,  cardiac 
failure,  etc.  The  author  knows  of  a  number  of  deaths  on  the  table 
where  paralysis  of  the  larynx  had  existed  unknown  to  the  surgeon ;  and 
a  perusal  of  surgical  literature  reveals  cases  strongly  suggestive  of  un- 
suspected laryngeal  paralysis. 

When  it  comes  to  operations,  however,  the  indirect  method  has  no 
place  in  the  author's  technic.  In  making  this  statement,  the  author 
wishes  to  qualify  it  by  saying  that  he  does  not  pretend  to  have  the  fa- 
cility in  indirect  operating  that  is  possessed  liy  man\-  of  the  laryngolo- 
gists,  who.  by  a  lifetime  of  training,  have  acc|uiretl  wonderful  skill  in 
working  by  the  aid  of  the  reversed  image  seen  in  the  mirror.  The  skill 
of  such  men  as  Delavan,  Semon,  St.  Clair  'J'homson,  liryan,  rrench,  Cur- 
tis, McKernon,  Simpson,  Tilley,  Dundas  Grant.  Moritz  Schmidt  and 
others  in  overcoming  tlie  disadvantage  of  being  compelled  to  move  a 
forceps  backward  when  it  is  desired  to  bring  it  forward,  and  to  make 
a  diagonal  movement  by  combining  a  reversed  antero-posterior  and  a 
true  lateral  movement,  is  marvelous  and  probablv  will  not  be  e(|ualled 
b\'  any  future  generation  of  laryngologists  because  there  is  not  now  the 
incentive  to  spend  the  lifetime  at  practice  necessary  to  acquire  the  skill 
to  work  under  the  peculiar  circumstances  of  having  the  antero-i)osterior 
movement  reversed  while  the  lateral  movements  are  unchanged.  This 
must  not  be  taken,  however,  to  mean  that  good  work  can  be  done  by  the 
direct  method  without  a  large  amount  of  jiractice,  nor  that  a  superlative 
degree  of  skill  cannot  be  acquired  in  the  direct  method.  The  same  amount 
of  work  will  produce  equally  marvelous  results  with  the  direct  method 
as  were  accomplished  by  the  indirect,  and  the  results  will  be  vastlv  great- 
er because  of  the  greater  possibilities  of  the  direct  procedure. 

\'ery  young  children,  because  of  their  being  intractable  and  terri- 
fied, are  difficult  cases  for  the  mirror-method  of  indirect  lar\ngoscopy, 
but  in  addition,  as  shown  by  Swain  (  Hib.  oOS),  the  epiglottis  adds  great- 


92  DIRECT   LARYNGOSCOPY. 

ly  to  tlie  difficulty  as  compared  to  the  adult  epiglottis.  Moreover,  the 
child's  epiglottis  is  prone  to  curl.  In  the  direct  method,  on  the  other 
hand,  we  have  a  method  by  which  the  larynx  of  any  infant  or  older 
child  can  be  examined  without  any  anesthesia,  general  or  local.  The 
erroneous  statement  that  anesthesia  is  required  has  crept  into  the  litera- 
ture, and  has  prevented  the  widest  use  of  direct  laryngoscopy  for  the 
diagnosis  of  the  various  causes  of  croupy  cough  in  children  too  young 
for  mirror  inspection.  Nearly  all  cases  of  papilloma  and  of  unsuspected 
foreign  body  in  the  larynx  have  had  diphtheria  antitoxin  given  because 
it  was  supposed  that  the  larynx  could  not  be  examined  v\-ithout  anes- 
thesia. Worse  still,  are  the  deaths  from  attempts  to  administer  an  alto- 
gether unnecessary  general  anesthetic  to  a  child  w-ith  a  stenosed  larynx. 

In  dyspneic  cases,  the  possibility  of  retropharyngeal  abscess  must 
be  borne  in  mind,  and  the  posterior  pharyngeal  wall  should  always  be 
carefully  inspected  before  bronchoscopy.  Of  course,  this  can  be  done 
with  the  lingers  by  palpation,  Iiut  ihe  most  ready  way  is  just  habitually  to 
note  the  condition  of  the  posterior  pharyngeal  wall  when  introducing  the 
direct  laryngoscope. 

Contraindications  to  direct  laryngoscopy.  The  author  can  recall  no 
absolute  contranidications  to  direct  laryngoscopy  in  any  cases  where  di- 
rect laryngoscopy  is  really  needed  for  either  diagnosis  or  treatment.  In 
extremely  dyspneic  cases  if  the  operator  is  not  prompt  and  certain  in  his 
introduction  of  a  bronchoscope  it  may  be  wise  to  do  a  tracheotomy  first. 

The  direct  laryngoscopic  appearances.  The  illustrations  in  this  book 
may  seem  a  little  queer  to  those  accustomed  to  the  old  indirect  illustra- 
tion. The  \iews  in  the  sitting  patient  seem  "upside  down."  Yet  simply 
to  re\erse  an  indirect  view  will  not  give  a  direct  picture  because  the  view 
point  is  different  as  already  explained.  The  epiglottis  does  not  show  be- 
cause it  is  hidden  by  the  direct  laryngoscope.  If  the  glottis  is  wideh 
open,  the  observer  looks  directly  into  the  trachea  in  the  direction  of 
its  long  axis;  and  therefore  does  not  see  one  tracheal  wall  any  more 
than  the  other,  if  the  head  and  neck  of  the  patient  are  placed  in  the 
proper  position.  All  the  indirect  illustrations  represent  the  rings  of  the 
trachea  showing  below  the  glottis.  If  the  patient  gets  his  head  too  far 
backward  (in  the  sitting  position),  the  anterior  wall  may  possibly  be 
thus  seen,  because  in  such  a  position  the  observer's  eye  is  back  of  the 
larynx  and  is  in  almost  the  same  position  with  reference  to  the  larynx 
as  is  the  mirror  in  indirect  laryngoscopy.  This  will  be  understood  by 
referring  to  Fig.  74.  But  this  is  a  very  wrong  position  for  direct  laryn- 
goscopy, as  elsewhere  herein  explained.  When  the  patient  is  in  the  posi- 
tion shown  in  Fig.  70.  the  posterior  wall  of  the  trachea  is  more  easilv 
seen  tlian  the  anterior,  though  if  the  position  is  exactlv  correct,  neither 


DIRKCT   LARYXGOSCOPV.  93 

will  be  more  conspicuous  tlian  the  other,  because  the  operator  will  be 
looking  directly  down  in  the  tracheal  axis.  If  the  posterior  wall  is 
viewed,  no  rings  will  show  because  the  posterior  wall  of  the  trachea 
is  devoid  of  cartilage  below  the  cricoid. 

Illustrations  of  the  laryngeal  image  on  mirror  view  have  always 
been  misleading.  They  are  semidiagrammatic  and  lack  depth.  This  is 
one  of  the  things  that  contributes  most  to  the  disappointment  of  the  be- 
ginner in  direct  larAiigoscoiJy.  He  never  knew  that  the  vocal  cords  were 
so  deep.  They  are.  in  the  adult,  nearly  :!  cm.  below  the  aryepiglottic 
folds,  and  not  almost  on  a  level  with  them  as  illustrations  of  indirect 
views  have  usuallv  pictured  them.  \\'hen  the  beginner  in  endoscopy 
examines  them  directly,  and  still  more  when  he  first  attempts  to  operate 
upon  them,  they  seem  almost  hopelessly  far  away  ;  and  to  make  matters 
worse  they  are  quite  likely  to  be  obscured  from  time  to  time  by  spas- 
modic narrowings  of  the  lumen  by  the  false  bands  and  even  by  the  up- 
per orilice  of  the  larynx  posteriorly.  The  illustration.  Fig,  !•,  Plate  1, 
gives  some  idea  of  the  depth  of  the  larynx  because  the  hand  stretches 
across  near  the  level  of  the  lop  of  the  false  bands.  The  reasons  for  the 
misconceptions  as  to  the  real  depth  of  the  cords  are  four:  1.  Illustra- 
tions of  the  larynx  are  made  from  memory  and  are  always  more  or  less 
diagrammatic,  i.  The  cords  are  the  central  point  of  interest  and  are 
unconsciously  always  strongly  represented  in  the  illustrations  with  a 
glistening  whiteness  that  brings  them  right  up  to  the  nearest  plane  in  the 
laryngoscopic  picture.  ;!,  Text-book  tradition  has  called  them  white 
so  that  white  they  are  painted,  it  matters  not  whether  they  are  ^ray, 
l^early,  dark  greenish  gray,  bituminous,  yellowish  pink,  bluish  pink, 
bright  pink,  or  tinged  by  reflected  light.  The  artist  giving  them  their 
true  color  value  would  make  them  stand  back  at  their  true  depth.  But 
it  takes  a  lifetime  to  train  the  artist's  eye  to  see  values,  and  it  takes  an- 
other lifetime  to  train  the  laryngologist  to  see  laryngcs,  Conse- 
quentl\-  there  are  no  artist-laryngologists,  \.  There  is,  owing  to  well-known 
o])tical  laws,  an  actual  foreshortening  of  the  laryngeal  image  as  seen  in 
the  laryngeal  mirror.  If  anyone  doubts  the  author's  statement  that  the 
cords  are  rarely  reallv  white,  let  the  doubter  compare  the  whiteness  of 
some  cases  of  painlloma  or  of  the  while,  grass-like  projections  sometimes 
seen  in  certain  cases  of  malignancy,  A  good  demonstration  of  the  fore- 
shortening affect  of  the  mirror  is  apparent  in  comparing  the  flat  ribbon- 
like appearance  of  the  cords,  with  their  actual  a[)pearance.  This  ribbon- 
like appearance  is  not  so  much  in  evidence  with  the  direct  method,  and 
when  the  larynx  is  opened  by  ihyrolomy  it  is  seen  to  have  been  an  illu- 
sion.    (See  Figs,  SI  and  -ISS). 


91  DIRKCT  LARYNGOSCOPY. 

Ill  Studying  the  direct  laryngoscopic  image  it  must  be  remembered 
that  tlie  lary-nx,  like  the  face,  is  full  of  muscles  and  is  changing  its  ex- 
pression every  moment.  The  laryngologist  who  sketches  as  accurately  as 
he  can  will  notice  that  no  two  sketches  are  exactly  alike.  The  author 
has  been  criticised,  by  students  who  did  not  understand  this,  for  repre- 
senting the  same  epiglottis  or  the  same  larynx  differently  at  different 
times.  It  is  only  under  the  most  profound  anesthesia  with  abolition  of 
all  except  the  deep  reflexes  that  wc  see  the  glottic  chink  enlarge  and 
diminish  in  perfect  rhythm  with  the  respiratory  movement  without  ac- 
ccssor\-  movements  in  any  part.  And  even  then  symmetrv  may  be  in- 
terfered with  by  distortive  instrumental  traction.  Without  anesthesia 
there  is  usually  more  or  less  spasmodic  traction  of  the  arytenoids,  and 
the  ventricular  bands  are  \ery  apt  to  close  o\er  the  cords  and  to  narrow 


Fk;.  75. — Direct  laryngoscopic  views  local,  partial  or  no  anesthesia.  A,  epi- 
glottis. (It  is  often  more  curled  than  this.)  First  stage  of  direct  laryngeal  ex- 
posure. B,  laryn.x  exposed  but  orifice  is  narrowed  by  spasm.  C,  a  moment  later 
when  orifice  widens  and  .i;lottis  opens  on  deep  inspiration.  D,  posterior  part  of 
larynx  as  usually  seen  at  beginning  of  third  stage.  This  is  more  frequently  seen 
than  B.  If  the  larynx  should  open  it  would  be  seen  that  a  much  larger  portion 
of  the  glottis  is  visible  than  anticipated. 

the  upper  laryngeal  orifice,  so  that  no  cords  are  visilile.  This  jiertains. 
to  some  extent,  even  under  quite  perfect  local  anesthesia.  The  picture 
is  very  apt  to  be  as  shown  at  D  in  Fig.  7~>.  consisting  of  two  rounded 
masses  posteriorally  with  more  or  less  showing  of  the  rounded  masses 
anteriorally,  corresponding  to  the  \entricular  bands.  If,  however,  the 
])atient  is  commanded  to  keep  on  breathing  and  not  to  hold  his  breath, 
the  lirst  deep  inspiration  will  open  up  the  glottis  and  then  the  view 
should  be  as  at  C  in  Fig.  7."),  except  that  it  is  not  often  that  the  begin- 
ner will  be  able  to  expose  the  anterior  commissure  as  there  shown. 

The  field  of  vision  at  any  particular  moment  appears  much  larger 
than  the  diameter  of  the  tube,  and  the  author  has  so  drawn  and  painted 
it  in  the  illustrations.  The  field  actually  is  larger,  the  degree  being  de- 
pendent upon  the  distance  of  the  obiect  viewed  from  the  distal  end  of  the 


DIRKCT  T.ARYXC.OSCOPV.  d'i 

tul)c  moulli  as  will  he  understood  by  reference  to  Fig.  TG;  but  this  fac- 
tor, of  course,  in  a  long  tube  of  small  lumen,  is  ver}'  slight  unless  the 
object  be  very  far  from  the  distal  tube-mouth.  What  contributes  more 
to  the  apparently  larger  size  of  the  field  as  compared  to  the  tubal  diameter 
is  the  general  law  of  optics  which  explains  why  the  farther  away  an 
object  is  from  the  eye,  the  smaller  the  image,  and  consequently  the 
greater  the  area  visible.  Perspective  contributes  also  the  additional  fact 
that  the  nearer  the  plane  of  a  receding  surface  approaches  the  visual 
axis  the  greater  the  foreshortening,  and  the  greater  the  foreshortening 
the  greater  the  area  visible.  In  plain  language  the  nearer  a  surface  ap- 
proaches to  being  seen  on  edge,  the  greater  the  area  visible  through  an 
aperture  of  a  certain  size  placed  at  a  certain  distance  from  the  eye. 
Hence,  in  endoscopically  \iewed  surfaces  close  against  the  tube-mouth, 
and  vertical  to  the  axis  of  the  tube,  we  see  an  area  equivalent  to  that  of 
the  lumen  of  tin-  tube  niDUtli.  whereas  in   \iewing  surfaces  receding  in 


C 


B 


Fjg.  76, — Schema  .sliouiiv^  one  of  the  reasons  why  the  endoscopic  image  always 
seems  larger  than  the  actual  diameter  of  the  tube  tlirough  which  it  is  seen.  This 
is  most  apparent  with  the  direct  laryngoscope.  The  field  of  vision  is  larger  in  pro- 
portion as  the  distance  between  the  tube-month,  A  P.,  and  the  farther  limit  of  the 
visible  field,  C    D.  increases. 

planes  more  or  less  approaching  parallelism  with  the  tubal  axis  we  see 
areas  ec|uivalent  to  many  times  the  area  of  tubal  aperture. 

Inslntctions  to  patients.  I'.efore  beginning  endoscopy  the  patient 
should  be  told  that  he  will  feel  a  very  disagreeable  pressure  on  his  neck 
and  that  he  mav  feel  as  if  he  were  about  to  choke,  and  that  he  cannot 
get  his  breath,  lie  must  be  gently  biU  lirmly  made  to  unilersland:  1  1  )  that 
while  the  procedure  is  alanning  that  it  is  absolutely  free  from  danger: 
(2)  and  that  you  know  just  how  it  feels;  (;i)  and  that  you  will  not  al- 
low his  brealli  In  lie  sluil  oil  completely;  1  I  1  ibal  be  can  help  you  \er\' 
greatly  as  well  as  make  the  ])rocedure  very  much  easier  for  himself  by 
paying  close  attention  tn  breathing  very  dee])ly  and  regularly,  in  anil 
out;  (.5)  lli;U  he  must  not  diaw  himself  up  rigidU  as  if  he  were  "walking 
on  ice,"  but  must  be  easy  and  relax.  It  will  contribute  very  much  to 
this  end  if  the  operator  will  be  particularly  gentle  and  careful  about  the 
earlv  manipulations  of  applying  the  local  anesthetic  and   the  like;  and 


96  DIRIXT   LARVNCOSCOPV. 

\vi11  tell  tlio  pntie-nt.  after  the  epiglottis  is  exposed  ami  tlie  application  of 
the  local  anesthetic  made  to  it.  that  there  will  be  nothing  worse  to  be 
gone  through  with.  Some  endoscopists  advocate  telling  the  patient  to  put 
up  his  hand  if  the  procedure  is  too  severe.  The  author  prefers  not  to 
do  this  because  it  leads  the  patient  to  think  that  he  is  about  to  go  through 
a  severe  ordeal  which  he  may  not  be  able  to  survive,  and  that  he  must 
give  notice  of  impending  death.  Moreover,  he  is  apt  to  raise  his  hand 
and  grasp  the  instrument  or  the  operator's  hand.  It  is  better  to  have 
the  patient's  hands  held  down  by  a  nurse.  However,  each  operator  will 
develop  his  own  method  of  controlling  the  patient  and  the  author  does 
not  care  to  urge  his  own  method  too  strongly.  A  suggestion  of  Mr. 
\\"aggette  (Bib.  5GT)  is  particularly  good:  Namely  that  a  special  signal 
be  arranged  by  which  the  patient  may  inform  the  operator  that  the  lips  or 
teeth  are  being  painfully  pressed  upon.  The  operator  interested  in  his 
deeper  work  may  otherwise  overlook  this  little  detail  which  is  often, 
needlessly  the  painful  part  of  the  procedure. 

Technic  of  exposure  of  the  larynx  in  tlic  sittiiu/  patient.  Exposing 
the  lar\  nx  with  the  speculum  in  the  sitting  position  should  be  approached 
from  the  standpoint  of  depressing  the  tongue  to  find  the  epiglottis  and 
then  depressing  and  drawing  forward  the  epiglottis,  tongue  and  all  tis- 
sues attached  to  the  hyoid  bone.  By  keeping  this  constantly  in  mind, 
two  of  the  greatest  difficulties  and  errors  will  be  prevented;  namely,  (1) 
the  tendency  on  the  part  of  the  patient  to  throw  his  head  far  back  as  if 
he  were  about  to  have  his  neck  shaved,  and  (3)  the  tendencv  on  the 
part  of  the  operator  to  follow  the  patient  and  thus  to  get  his  elbow  high- 
er and  higher,  his  own  head  farther  back  and  to  use  the  patient's  upper 
teeth  as  a  fulcrum  in  an  effort  to  pry  open  the  larynx,  a  movement  that 
defeats  its  own  object.  To  avoid  this,  the  author  sits  on  a  stool  in  front 
of  the  patient  precisely  as  if  he  were  about  to  use  a  tongue  depressor 
to  examine  the  pharynx.  The  position  of  the  operator  shown  in  Fig. 
70  is  the  highest  that  should  be  attained  at  the  complete  exposure  of 
the  larynx  when  the  operator  is  looking  directly  into  the  trachea.  In 
beginning  to  introduce  the  laryngoscope  the  operator  should  stoop  much 
lower,  having  his  head  about  level  with  iliat  of  the  patient.  (Fig.  77). 
The  introduction  of  the  instrument  should  be  considered  in  three  stages. 

1.  Exposure  and  identification  of  the  epiglottis. 

2.  Placing  the  spatular  tip  back  of  the  epiglottis. 

3.  Anterior  downward  traction  on  the  epiglottis  and  all  the  tis- 
sues attached  to  the  hyoid  bone. 

First  stage.  The  patient's  head  being  covered  with  a  sterile  cap, 
the  second  assistant  pushes  llie  patient's  head  and  neck  forward  as  shown 
in  Fig.  70.     The  operator  holds  the  laryngoscope  in  his  left  hand   (Fig. 


DIRliCT  LARYNGOSCOPY. 


97 


Fig.  77. — ']"lic  upper  illustratinii  vli,,w^  tlif  tii>l  ^taLji'  dI"  iliruii  lar\  iignscop.v. 
The  operator  is  insertint^;  the  laryngoscope  with  his  left  hand  while  he  holds  the 
patient's  upper  lip  out  of  the  way  with  the  right  inde.\  finger.  In  order  to  show 
the  instrument  and  the  operator's  hands  the  operator  is  standing  to  one  side  of 
the  patient.  In  actual  work  the  operator  sits  squarely  in  front  of  the  patient  as 
shown  in  the  lower  illustration. 


98 


DIRECT   LARYNGOSCOPY. 


77)  while  with  his  right  index  he  raises  the  patient's  upper  Hp  so  that 
it  cannot  be  pinched  between  the  laryngoscope  and  the  teeth.  The  distal 
end  of  the  laryngoscope  is  passed  backward  over  the  median  line  of  the 
dorsum  of  the  tongue,  and.  depressing  the  tongue,  in  the  direction  of  the 


.^av 

^  "^^ 

Fig.  78. — Schema  showing  the  first  and  third  stages  in  e.xposing  the  laryn.x  in 
direct  laryngoscopy.  At  the  left  the  tongue  is  being  depressed  as  indicated  by  the 
dart,  causing  the  epiglottis  to  project  into  the  line  of  vision  as  shown  in  the  lower 
illustration.  Then  the  laryngoscope  is  inserted  deeper  constituting  the  second  stage. 
At  the  right  is  shown  the  third  stage,  the  drawing  forward  of  the  epiglottis  and  all 
of  the  tissues  attached  to  the  hyoid  bone  with  the  tip  of  spatular  end,  thus  exposing 
the  spasmodically  closed  larynx  as  shown  in  the  lower  right  hand  illustration.  At 
the  next  inspiration  the  larynx  will  open,  exposing  the  cords  and  glottis  as  shown 
in  Fig.  75.     (See  Fig.  70  for  photograph  of  the  positions  at  the  third  stage.) 


dart  in  the  left  half  of  Fig.  78,  the  upper  edge  of  the  epiglottis  will  come 
into  view,  as  shown  in  the  circle.  The  tongtie  is  depressed  until  the 
epiglottis  stands  up  rather  prominently  like  the  spout  of  a  pitcher,  and 
shows  a  goodly  portion  of  its  anterior  surface.  Absolutely  no  effort 
should  be  made  to  see  the  larynx  until  the  first  stage  is  accomplished. 


DIRICCT   LARYNGOSCOPY.  99 

namely,  the  identification  of  the  epiglottis.  If  it  fail  to  come  into  view,  it 
must  he  searched  for  a  little  more  to  the  right  or  to  the  left;  hut  deep 
insertion  must  he  strictly  avoided.  Failure  to  find  the  epiglottis  nearly 
always  means  too  deep  insertion  ;  hecause,  if  the  first  step  is  properly 
taken,  namely,  to  depress  the  dorsum  of  th.e  tongue  slightly  until  the 
epiglottis  comes  up  into  view,  and  if  the  speculum  is  exactly  in  the 
median  line,  the  epiglottis  will  promptly  project  upward  right  in  the  line 
of  vision,  with  the  lingual  surface  of  the  epiglottis  toward  the  operator, 
as  shown  in  A,  Fig.  75,  and  in  the  left  hand  circle  in  Fig.  78. 

Second  stage.  Having  identified  the  epiglottis  in  the  manner  just 
described,  the  next  step  is  to  pass  the  spatular  end  of  the  speculum  pos- 
teriorally  to  the  epiglottis  for  a  distance  of  about  1  cm.  or  l..j  cm. 
(slightly  less  than  1  cm.  in  a  child).  The  depth  of  insertion  cannot  be 
gauged  by  arbitrary  measurements.  Nothing  but  experience  will  enable 
the  operator  to  get  it  exactly  right  for  the  particular  case,  since  the  ne- 
cessary distance  is  subject  to  wide  individual  variations.  If  the  depth  is 
not  correctly  gauged  the  error  will  be  revealed  in  the  third  stage. 

Third  static  Witiiout  permitting  the  laryngoscope  to  go  deeper, 
the  larynx  is  exjic^sed  by  a  movement  of  the  spatular  end  of  the  laryn- 
goscope in  the  direction  of  the  dart  in  the  right  half  of  Fig.  78.  This 
movement  is  fundamental  in  c\])osure  of  the  larynx.  It  is,  perhaps,  best 
described  as  an  eft'ort  to  pull  the  epiglottis  and  hyoid  bone  downward, 
outward  and  forward  toward  the  oi)erator  with  the  tip  of  the  spatular 
end.  The  patient's  whole  head  i^hould  be  inilled  forward  by  the  power 
exerted.  If  this  is  kept  in  mind  there  will  be  no  danger  of  falling  into 
the  error  of  trying  to  pry  open  the  larynx  using  the  upper  teeth  as  a 
fulcrum.  If  the  operator  expects  now  to  see  the  larynx  as  in  the  laryn- 
geal mirror,  lie  will,  in  most  instances,  be  disappointed  for  reasons  al- 
ready given.  Usually  a  spasm  of  the  larynx  hides  the  cords  from  view 
and  all  that  is  seen  is  the  two  rounded  eminences  over  the  arytenoids. 
The  jjatient  must  be  encouraged  and  jiacificd  if  alarmed,  and  must  be 
frequently  admonished  to  breathe  deeply.  .\l  the  first  inspiration  the 
cords  will  be  seen  more  or  less  hidden  by  the  overhanging  ventricular 
bands,  if  the  laryngoscope  is  properly  ])laced  and  the  effort  of  the  oper- 
ator's left  hand  is  properly  exerted.  It  re(|uires  considerable  strength 
and  endurance  in  the  wrist  to  hold  oul  (jf  the  way  the  tissues  of  a  mus- 
cular ])atient  with  a  shoii  thick  neck.  If  tlu-  cords  are  seen,  then  it  is 
known  that  the  laryngoscope  is  properly  placed  and  that  no  harm  can 
Ije  done  by  firm  ])ulling  in  the  proper  direction,  provided  the  instrument 
is  in  the  middle  line.  If  in  executing  the  third  ^t.•Lge  the  epiglottis  slips 
away  downward,  the  insertion  of  the  second  stage  has  not  been  deep 
enough,  and  the  ejiiglottis  must  be  very  carefully  identilied  again  and  the 


100  DIRItCT    I.ARVXC.OSCOPV. 

insertion  made  slightly  deeper.  If  a  hasty  movement  is  made  to  catch 
the  epiglottis  the  aryepiglottic  fold  may  be  mistaken  for  the  epiglottis 
and  then  forward  traction  will  expose  the  corresponding  pyriform  sinus; 
which  is  bewildering  to  tlie  beginner  who  concludes  that  the  larynx  is 
hard  to  find.  If.  on  the  other  liand,  in  executing  the  second  stage  the 
laryngoscope  is  inserted  too  deeply,  the  hypo-pharynx  will  be  entered  and 
the  third  stage  will  fail  to  expose  the  larynx  and  very  strong  muscular 
effort  will  result  in  exposing  the  pyriform  sinuses  or  even  the  mouth  of 
the  esophagus. 

Difficulties.  If  careful  attention  has  been  given  to  all  the  instruc- 
tions as  to  position  of  patient  and  operator  and  to  the  successive  execu- 
tion of  each  of  the  three  stages,  there  should  be  no  great  difficulty  in  suc- 
ceeding in  an  average  case  after  a  few  trials.  But  it  is  by  no  means  easy 
to  execute  every  detail  correctly,  especially  without  a  trained  assistant.  If 
the  head  of  the  patient  has  l)een  allowed  to  rotate  or  to  deviate  laterally, 
the  larv'Hx  will  not  seem  to  be  where  it  ought  to  be — in  the  median  line. 
If  the  laryngoscope  has  not  been  held  firmly  in  the  middle  line,  the  same 
"lost  larynx"  may  result  from  the  distortion  due  to  the  slipping  sidewise 
of  the  tongue  and  its  attachments.  If  the  laryngeal  aperture  cannot  be 
found  the  patient  should  be  allowed  a  moment's  rest  during  which  he  can 
expectorate  secretions.  Each  time  the  instrument  is  removed  it  should  be 
wi]jed  clean  with  a  square  of  gauze,  because  a  patient  does  not  like  even 
his  own  saliva  put  back  in  his  mouth.  The  same  movement  wipes  the 
lamp.  Then  a  fresh  start  should  be  made.  If  the  larynx  still  fails  to  be  re- 
vealed the  endoscopist  should  ask  himself  which  of  the  hereinafter  given 
"rules"  he  has  violated.  If  the  larj'nx  is  correctly  exposed  squarely 
before  the  Iar\-ngoscope,  but  only  the  posterior  commissure  is  visible 
even  on  deep  inspiration,  the  pulling  with  the  tip  of  the  spatular  end 
should  be  increased  and  the  patient's  head  should  be  brought  further 
forward  toward  the  operator,  and  extension  lessened  rather  than  in- 
creased. If  the  anterior  commissure  still  fails  to  appear  the  second  as- 
sistant who  holds  the  head  should,  with  his  right  index  linger  externally 
on  the  neck,  pull  the  thyroid  cartilage  backward.  If  properly  done,  this 
will  expose  the  anterior  commissure  in  any  case,  and  this  is  often  neces- 
sary, in  order  to  counteract  the  forward  traction  of  the  larynx  by  its  at- 
tachments to  the  hyoid  bone.  Like  all  purely  manual  procedures,  practice 
is  required  to  render  direct  laryngoscopy  easy  and  smooth  in  its  execu- 
tion, which  is  a  matter  entirely  separate  from  knowiiicj  hozv  to  do  it. 

Ria.Ks  roR  niKiiCT  l.\ryxc.()scoi>y. 

1.  The  laryngoscope  must  always  be  held  in  the  left  hand,  never 
in  the  right. 


DIRIXT  LARYXGOSCOPV.  101 

2.  The  operator's  right  index  linger  (never  the  left)  should  be 
used  to  elevate  the  patient's  upper  lip  so  that  there  is  no  danger  of 
pinching  the  lip  between  the  instrument  and  the  teeth. 

■  K  The  patient's  head  must  always  be  exactly  in  the  middle  line. 
not  rotated  to  the  right  or  left  nor  bent  over  sidewise,  and  tbe  ennre  head 
must  be  forward  with  extension  at  the  occipito-atloid  joint  only.  (Fig. 
65). 

■1.  The  laryngoscope  must  always  be  passed  over  the  dorsum  of 
the  tongue  exactly  in  the  middle  line  (until  the  endoscopist  is  sutticiently 
skilled  to  try  the  obli(|ue  position  \. 

5.  The  ef)iglottis  must  always  be  identified  before  any  attempt  is 
made  to  expose  the  larynx. 

(J.  \\"hen  first  inserting  the  laryngoscope  to  find  the  epiglottis, 
great  care  should  be  taken  not  to  insert  too  deeply  lest  the  epiglottis  be 
overridden  and  thus  hidden 

7.  After  ideiititication  of  the  epiglottis,  too  deep  insertion  of  the 
laryngoscope  must  be  carefully  avoided  lest  the  spatula  be  inserted  back 
of  the  arytenoids  into  the  hypo-pharynx. 

S.  E.xposure  of  the  larynx  is  accomplished  by  pulling  forward  the 
epiglottis  and  the  tissues  attached  to  the  hyoid  bone,  and  not  by  prying 
these  tissues  forward  with  the  upper  teeth  as  a  fulcrum. 

!•.  Care  must  be  taken  to  avoid  mistaking  the  ary-epiglottic  fold 
for  the  epiglottis  itself.  (Most  likely  to  occur  from  rotation  of  the  pa- 
tient's head.) 

lu.  'JMie  tube  should  not  be  retained  too  long  in  place,  but  should 
be  removed  and  the  patient  permitted  to  swallow  the  accumulated  saliva, 
which,  if  the  laryngoscope  is  too  long  in  place,  will  trickle  down  into  the 
trachea  and  cause  cough.  (  Swallowing  is  almost  impossible  while  the 
laryngosco]ie   is  in  position). 

\\.  The  ])atienl  must  be  instructed  to  breallu'  dce])ly  and  i|uielly 
without  making  a  sound. 

12.  In  the  sitting  position  of  the  patient,  the  i>])erator  should  als(j 
be  sitting. 

Direct  laryiuioscopx  by  hitercil  and  oblique  methods.  In  the  fore- 
going description  of  the  technic  of  direct  laryngoscopy,  it  is  stated  that 
the  instruments  should  be  jiassed  exactly  in  the  middle  line  (i\er  the 
dorsum  of  the  tongue.  This  is  intended  to  render  orientation  easy.  After 
facility  is  acquired  and  the  faculty  of  readily  recognizing  various  land- 
marks is  developed,  it  will  be  found  a  great  advantage  in  exposing  the 
larynx  to  pass  the  laryngoscope  at  the  side  of  the  tongue  from  the  cor- 
ner of  the  mouth,  the  head  being  turned  very  slightly  toward  the  oppo- 
site side.     Otherwise  the  position  is  the  same  as  by  the  regular  method. 


102  DIRKCT   LAKYNGOSCOPY. 

As  the  exposure  is  obliciue,  the  larynx  will  look  somewhat  asymmetrical 
and  more  will  be  seen  of  one  wall  than  of  the  other.  This,  however,  is 
of  very  great  advantage  when  it  is  desired  to  inspect  the  ventricle,  the 
laryngoscope  being  passed  from  the  corner  of  the  mouth  opposite  to  the 
ventricle  to  be  examined ;  that  is,  through  the  right  corner  of  the  mouth 
when  the  left  ventricle  is  to  be  examined,  and  vice  versa.  The  oblique 
method  also  is  of  very  great  ad\antage  in  the  removal  of  tumors  from 
the  ventricle  and  from  the  subglottic  regions,  and  very  often  from  the 
cords  themselves,  the  speculum  being  passed  from  the  corner  of  the 
mouth  opposite  to  the  side  of  the  larynx  on  which  it  is  intended  to 
operate.  A  narrow  tube  laryngoscope  such  as  shown  in  Fig.  21  (child's 
size )  is  best  adapted  to  larvngoscopy  at  the  side  of  the  tongue.  The 
author  cannot  understand  Briinings'  objections  to  the  lateral  route. 

In  using  lateral  opening  specula  such  as  the  one  shown  in  Fig.  15, 
with  the  slide  oiT.  it  is  best  to  pass  the  instrument  to  one  side  of  the 
tongue,  selecting  the  side  that  will  leave  the  tongue  on  the  side  of  the 
instrument  that  has  no  opening.  If  the  tongue  is  on  the  side  of  the 
opening  the  tongue  will  crowd  into  the  opening,  and  obstruct  the  view. 
These  lateral  opening  specula,  however,  are  not  especiall)-  intended  for 
lateral  use.  They  are  useful  only  for  regular  dorso-lingual  passage  under 
general  anesthesia.     They  are  too  wide  for  use  under  local  anesthesia. 

Exposure  of  the  larynx  iintli  the  instruments  of  Briinings,  or  of 
Kahler,  and  with  all  modifications  of  these  and  of  the  author's  laryngo- 
scope, is  precisely  the  same  as  described  in  the  foregoing.  The  technical 
illustrations  show  the  author's  instrument  but  the  movements  are  identi- 
cal with  all  other  instruments  of  the  same  position  of  handle,  which  has 
come  to  be  universallv  employed  for  the  sitting  position.  The  simple 
L-shaped  laryngoscope  has  been  generally  abandoned  for  laryngoscopy 
upon  the  sitting  patient.  The  only  difiference  in  the  use  of  the  various 
laryngoscopes  for  this  purpose  is  in  the  management  of  the  illumination, 
proximal,  distal  or  headband  types.  Killian  uses  an  improved  form  of 
Kirstein  headlamj)  for  all  direct  laryngoscopic  procedures  except  for 
demonstration,  for  which  he  uses  the  handlamp  at  the  proximal  end  of 
the  tube. 

Subglottic  laryngoscopy.  For  examining  the  subglottic  region  in 
adults  the  child's  size  of  the  esophageal  speculum.  Fig.  21,  is  very  sat- 
isfactory. It  is  used  instead  of  the  laryngoscope  to  expose  the  larynx, 
and  then  it  is  gently  slid  down  into  the  glottis  while  carefullv  keeping  in 
view  the  two  arytenoid  eminences  as  the  tip  of  the  speculum  enters  the 
glottis.  In  children,  however,  the  author  prefers  to  insert  one  of  his 
regular  bronchoscopes.  Fig.  Ki,  because  the  instrument  is  extremely 
light  and   delicate,  therefore  there   is  no  danger  of   causing    subglottic 


DIRKCT    LARYNGOSCOPY.  103 

edema.  The  Briiiiings  and  Kahlcr  bronchoscopes  may  be  used  for  either 
ackilts  or  children  in  the  way  jnst  described  for  the  child's  esophageal 
speculum.  Great  care  should  be  used  in  thus  examining  the  subglottic 
region  of  children,  for  the  reason  given. 

THE    TKCIIMC   Ol"   IlIKKCT    L.\RYNC.i:.\L   OPKRATING. 

The  picl^amtioii  of  the  patient,  local  as  well  as  general,  should  be 
carried  out  as  elsewhere  herein  suggested.  Particular  attention  should 
be  given  to  oral  antisepsis,  however  trivial  the  growth  and  its  removal 
may  seem  to  be ;  and  the  general  examination  should  never  be  omitted 
except  in  great  emergency. 

Anesthesia  has  been  elsewhere  considered  in  detail.  For  direct 
laryngoscopy  upon  the  sitting  adult  patient  it  is  usually  local,  never 
general.  The  more  thoroughly  it  is  carried  out  the  easier  will  l)e  tlie 
operation,  because  of  the  lessening  of  the  reflex  spasm,  not  because  of 
need  of  analgesia.* 

Left-hand  exposure.  The  prime  essential  of  direct  laryngeal  oper- 
ating is  perfect  mastery  of  continuous  left-handed  laryngeal  exposure. 
The  left  hand  must  be  able,  unaided,  not  only  to  expose  the  larynx  but 
to  maintain  the  exposure  for  at  least  a  minute.  Many  operative  pro- 
cedures can  lie  completed  ni  this  time  if  a  ])roper  pl.in  of  working  has 
been  devised.  Those  that  ret[uire  a  longer  period  can  be  C(jmpleled  by 
removal  and  reinsertion  of  the  laryngoscojie.  The  author  personally 
finds  no  difficulty  in  holding  the  larynx  open  for  ten  tn  iifteen  minutes 
if  need  be,  and  Ur.  Jillen  J.  Patterson  has  fre(|uently  held  the  larynx 
exposed  for  a  twenty-tive  minute  radium  a[)plication.  Yet  most  oper- 
ators lind  prolonged  exposure  tiresome  ;  and  there  is  no  objection  to  in- 
termittent exposure,  with  intervals  for  ex])ectoration,  provided  the  e.x- 
posure  is  steady  and  efficient  with  the  left  hand  only.  This  is  not  at  all 
difficult  to  acquire  if  the  student  will  begin  right,  as  previously  ex- 
plained, and  follow  precisely  the  directions  herein  given  for  direct  laryn- 
geal exposure,  always  with  the  left  hand  only.  Like  all  purely  manual 
procedures,  especially  bimanual  procedures,  such  as  the  playing  of  mu- 
sical instruments,  what  seems  at  first  difficult  becomes  easy  with  prac- 
tice to  those  who  are  not  discouraged  by  early  ditficultics. 

Endoscopic  use  of  laryngeal  forceps.  Having  mastered  direct 
laryngeal  left-hand  exposure  the  next  step  is  to  learn  the  use  of   for- 

•Tlie  rellt'X  .spa.im  here  refeiieil  to  is  the  oidinar.v  Blottie  mi)vement.  The 
statement  of  .some  authors  that  the  interior  of  the  larynx  shouid  be  cocainized  to 
prevent  re.xpiratory  arrest  from  "vaBTU.s  rellexes"  can  only  refer  to  patients  under 
ijrenerai  nne.slhrsia.  possil)l.v  partially  iindei".  In  over  one  lh<Jiisand  dii-ect  laryngeal 
operations  and  bronehoscopiea  l)y  l>r.  I'alter.Mon  and  the  autiior  tliere  has  never 
been  an  arrest  of  respiration   when  no  anesthetic,  general  or  local,   was  used. 


104  DIRIX'T   LAUVNGOSCOPV. 

ceps.  A  multiplicity  of  forceps  for  the  removal  of  growth  is  quite  un- 
necessary and  is  really  a  great  hindrance  to  good  work.  It  is  far  better 
to  rely  upon  one  forceps  such  as  that  shown  in  Fig.  35,  and  by  culti- 
vating dexterity  with  this  instrument  all  the  different  forms  and  posi- 
tions of  growths  as  shown  in  Fig.  7!'  can  be  removed  with  far  greater 
precision  than  if  all  (littorcnt  forms  and  angles  of  jaws,  guillotines,  etc., 
are  tried  first  and  found  wanting.  \\'hen  the  one  forceps  is  mastered, 
others  may  be  added  as  found  desirable.  It  5s  the  author's  custom  to 
have  the  jaws  always  set  to  open  the  one  way — up  and  down.  If  any 
other  angle  may  seem  desirable,  the  forceps  are  tiu'ued  in  the  hand  even 
to  complete  reversal,  the  thumb  and  finger  exchanging  rings.  This  may 
not  appeal  to  many,  and  the  author  would  not  urge  it ;  but  he  does  espe- 


FiG.  79. — Indirect  views  of  different  types  of  laryngeal  growths.  A.  Multiple 
papilloniata  in  a  woman  of  25  years,  requiring  traclieotomy.  Cured  by  repeated 
direct  laryngoscopic  operations.  B.  Multiple  infra-glottic  tibro-papillomata  in  a 
woman  of  54  years,  cured  Ijy  direct  operations.  C.  Fibroma  attached  to  the 
under  surface  of  right  cord  at  the  anterior  commissure  in  a  man  of  39  years.  Cured 
by  a  single  removal.  D.  Subglottic  angioma  in  a  man  of  42  years.  All  of  these 
different  types  of  tumor  were  removed  with  the  one  form  of  tissue  forceps  (Fi,g.  .55) 
illustrating  the  Heedlessness  of  a  large  variety  of  forceps. 

cially  urge  that  all  early  practice  work  be  done  with  the  one  forceps  and 
with  the  jaws  opening  only  one  way  until  the  eye  is  trained  to  watch  the 
forceps  open  and  close. 

The  gauging  of  depth  by  the  use  of  one  eye  only  is  at  all  times 
difficult  except  by  prolonged  practice.  It  is  more  than  usually  difficult 
in  direct  laryngeal  operating  because  of  the  misconception  as  to  the 
real  depth  of  the  larynx,  as  before  mentioned.  These  two  factors 
contribute  to  such  accidents  as  shown  at  B,  in  Fig.  SO,  where,  in  the 
attempt  to  reach  a  growth  of  the  cord,  miscalculation  as  to  the  real  depth 
of  the  growth  and  of  the  cord  from  which  it  sprung  caused  the  oper- 
ator, who  was  a  very  skillful  man  by  the  indirect  method,  to  punch  out  a 
section  of  the  ventricular  band  leaving  the  floor  of  the  ventricle  ex- 
posed to  view.  While  this  is  not  a  \crv  grave  accident,  if  not  too  far 
posteriorly,  it  is  one  to  lie  a\()i(led  on  the  general  principle  that  all  un- 


DIRECT  I.ARYNC.OSCOPV.  105 

necessary  laryngeal  trauma  is  always  to  be  avoided  with  the  utmost 
care,  because  onlv  by  so  doing  can  we  hope  for  the  highest  percentage 
of  good  results.  Serious  vocal  impairment  may  result  from  such  an  ac- 
cident if  relatively  deep  down  i)osteriorly.  A  still  more  serious  acci- 
dent is  seen  at  C.  where  a  large  jjart  of  the  left  cord  was  afterward  dis- 
covered at  indirect  laryngoscopy  to  have  been  punched  away  leaving 
the  fibroma  unharmed.  Worse  yet  is  the  accident  shown  at  D,  where  a 
large  part  of  the  arytenoid  cartilage  has  been  removed  and  the  arytenoid 
mo\ements  jiermanently  imjiaired.  As  shown  by  the  author  the  chief 
factor  in  the  jiroduction  of  an  efficient  adventitious  vocal  cord  is  the 
traction  of  an  unimpaired  ar\tenoid.  L'nfortunately  misdirected  excisions 
are  espccialh-  liable  to  be  located  posteriori}'.     Only  by  practice  can  the 


Fig.  8o. — A  direct  view  showing  hiding  of  the  end  of  the  forceps  by  spasmodic 
closure  of  the  ventricular  bands.  At  the  same  moment  the  upper  orifice  of  the 
larynx  closes  somewhat  also,  though  this  is  not  shown  in  order  to  illustrate  the 
spasmodic  closure  of  the  bands.  The  operator  thinking  his  forceps  correctly  placed, 
closes  tlicni,  and,  later  at  inchrcct  laryngoscopy,  is  surprised  to  find  the  ventricular 
band  cut  away  and  the  growth  below  unharmed,  (B).  A  worse  accident  is  sliown  at 
C  where  llie  posterior  half  of  the  cord  is  removed  leaving  the  fibroma  unharmed. 
Still  more  serious  is  the  accident  at  D,  where  a  large  part  of  the  left  arytenoid  was 
removed.  ( B,  C,  and  D  were  sketched  by  the  author  from  cases  seen  in  mnsulta- 
tion  immediately  after  the  accident.) 

faculty  of  gauging  tlepth  be  actiuircd.  and  especially  by  practice  which 
enables  the  operator  to  work  with  both  eyes  open,  ignoring  the  image 
of  the  left  eye.  A  darkened  room  assists  in  acquiring  this  faculty.  If 
the  habit  of  holding  the  left  eye  closed  is  formed,  the  vision  of  the  right 
eye  is,  for  the  tiine  being,  impaired  and  the  operator  is  needlessly  fa- 
tigued, as  pointed  out  by  the  author  many  years  ago.  Another  factor 
in  the  avoidance  of  the  accidents  above  referred  to  is  to  make  it  a  ruk' 
to  work  only  by  sight.  The  jaws  must  be  seen  to  close  properly  on  the 
growth,  otherwise  they  nuist  not  be  closed.  In  the  event  of  a  spasmodic 
contraction  of  the  laryn.x,  gras]iing  the  forceps  as  shown  at  A.  in  Fig 
SO,  the  forceps  should  be  withdrawn  and  if  working  under  a  local  anes- 
thetic more  nf  the  anesthetic  solution  should  be  ai)i)lied.     If  working  un- 


106  DiRr:cT  laryngoscopy. 

(ler  a  general  anesthetic,  (recumbent  patient)  the  depth  of  the  anes- 
thesia should  be  increased.  If  working  without  an  anesthetic  an  oppor- 
tunity must  be  awaited  when  the  larynx  is  free  from  spasm.  A  child 
will  clean  its  throat  by  swallowing  or  the  secretions  will  drain  out  if  the 
child  is  turned  over.  If  the  field  is  covered  with  blood  or  secretions, 
rendering  accurate  guidance  of  the  forceps  impossible,  the  larjngoscope 
and  forceps  must  be  removed  and  the  patient  told  to  "clear  his  throat.' 
If  a  growth  at  the  anterior  commissure  fails  to  come  into  view,  the  as- 
sistant holding  the  head  uses  his  inde.x  finger  to  press  backward  the 
thyroid  cartilage,  at  the  same  time  steadying  it,  and  this  counterpressure, 
when  properly  exerted  will  bring  into  view  the  anterior  commissure  in 
any  case  where  the  endoscopist  is  holding  his  speculum  properly.  Either 
lateral  wall  above  or  below  the  commissure  can  be  rendered  prominent 
by  skilled  counterpressure.  Under  no  circumstances  should  the  operator 
attempt  to  reach  a  growth  anteriorly  that  he  cannot  see,  simply  from  his 
memory  of  its  location  at  previous  indirect  laryngoscopy. 

In  the  removal  of  small  tumors,  either  on  the  cords  or  below,  it  is 
often  a  very  great  advantage  to  introduce  the  speculum  and  to  work  from 
the  opposite  side;  therefore,  in  rightsided  tumors,  the  speculum  is  put  in 
the  left  side  of  the  mouth  and  on  the  left  side  of  the  patient's  tongue. 
Then  by  moving  the  patient's  head  to  the  right,  we  get  a  good  view  of 
the  right  wall  of  the  larynx.  In  very  sensitive  adult  patients,  it  may  be 
wise  to  make  an  application  of  8  per  cent  cocaine  solution  along  the  side 
of  the  tongue  at  the  back,  on  the  side  through  which  the  speculum  is  to 
be  passed.  To  those  who  try  this  method  for  the  first  time,  there  may 
be  some  trouble  with  the  tongue  rolling  over  the  open  portion  of  the 
speculum  and  obstructing  the  view,  but  the  operator  soon  learns  to  con- 
trol this.  In  tumors  below  a  cord  (as  at  D,  Fig.  7!)j  there  is  a  great 
temptation  to  use  a  sliding  punch  forceps,  which,  however,  is  almost  cer- 
tain to  remove  the  cord  and  muscular  tissue.  A  better  method  is  to  tilt 
the  cord  over  sidewise  with  the  spatular  end  of  the  laryngoscope  and  the 
growth  thus  can  be  presented  fairly  in  front  of  the  spatula  by  extreme 
lateral  movement,  as  shown  in  Fig.  80,  and  by  pushing  firmly  on  the 
laryngoscope.  Then  the  tissue  forceps  (Fig.  35)  can  be  accurately 
placed  without  the  growth  slipping  away.  When  the  patient  coughs  up 
much  blood  the  lamp  may  become  somewhat  obscured.  Conditions  here 
are  very  different  from  work  in  the  tracheo-bronchial  tree  and  in  the 
esophagus  because  in  the  latter  two  regions  the  tube,  when  introduced,  is 
allowed  to  remain  throughout  the  entire  procedure,  and  the  swabs  with 
which  the  field  is  wiped  also  at  the  same  time,  without  any  effort,  wipe 
the  lamp.  In  the  larynx,  however,  working  as  is  almost  invariably  the 
case,  with  local  anesthesia  or  with  none  at  all,  the  direct  larj'ngoscope 


DIRECT  LARYNGOSCOPY.  1(J7 

is  frequently  withdrawn,  and  then  reintroduced  after  the  patient  has 
been  permitted  to  expectorate  tlie  blood  and  mucus.  At  these  inter- 
vals the  sjiatular  end  of  the  direct  laryngoscojie  is  wiped  by  the  operator 
with  a  square  of  gauze  witliout  removal  of  the  light  carrier.  This  wip- 
ing cleanses  the  portion  of  the  lamp  which  emits  the  light  needed.  There 
is  no  need  to  cleanse  the  back  of  the  lamp  nor  the  socket,  nor  the  little 
pocket  in  which  the  lamp  lies.  In  working  with  the  hand  lamp  the  mir- 
ror is  cleansed  of  the  spattered  coughed-out  secretions  at  these  removals. 
With  the  head  lam])  the  lens  front  and  mirror  are  to  be  similarly  cleansed 
and  readjusted  in  the  visual  axis.  With  the  Claar  reflector  the  mirror 
and  lamp  both  are  cleansed  and  readjusted  to  position  before  the  eye. 
With  any  of  these  forehead  forms  of  illumination  a  nurse  should  be  in- 
structed as  to  this  cleansing  so  as  to  minimize  the  loss  of  time. 

In  the  foregoing  the  author  has  referred  only  to  the  one  kind  of 
forceps.  By  this  he  does  not  wish  to  disapprove  of  sliding-punch  for- 
ceps. On  the  contrary,  punch  forceps  are  very  useful  at  times,  but  their 
use  should  not  be  attempted  until  the  operator  is  quite  familiar  w^ith  di- 
rect laryngeal  operating,  because  of  the  greater  liability  to  such  acci- 
dents as  shown  at  B  and  C  in  Fig.  80. 

Taking  of  a  laryngeal  specimen  for  diagnosis.  This  work  is  not 
concerned  with  diagnosis,  yet,  it  may  be  said  in  passing  that  the  diagnosis 
of  carcinoma  rests  largely  upon  the  histologic  examination.  The  diag- 
nosis of  sarcoma  rests  largely  on  the  exclusion  of  laryngeal  tuberculosis 
by  histologic  and  bacillary  tissue  examinations,  animal  injections  of  tis- 
sue, emulsions,  etc. ;  and  on  the  exclusion  of  lues  by  the  therapeutic, 
the  Wasscrniann  and  the  luetin  tests.  But  for  biopsy  to  be  of  any  value 
either  positively  or  negatively,  it  is  essential  to  have  an  ample  specimen. 
In  the  old  days  the  minute  fragment  from  an  uncertain  location  was  a 
disgrace  to  the  laryngologist,  an  enormity  of  injustice  to  the  microsco- 
pist  and,  worst  of  all.  to  the  patient.  Too  often  the  so-called  "specimen"' 
w'as,  as  aptly  described  by  Jonathan  Wright  (Bib.  582)  "A  tiny  bit  of 
tissue  chipped  off  the  surface  of  a  laryngeal  growth  with  a  pair  of  for- 
ceps, nay,  not  even  surely  off  the  growth,  but  ])erhaps  from  some  other 
part  of  the  endo-laryngeal  surface  in  tin-  neighborhood  of  the  growth, 
with  the  assertion  from  the  operator  that  it  did  come  from  the  growth." 
Direct  laryngo.scopy  for  the  removal  of  a  specimen  has  changed  all  this. 

The  best  plan  for  the  removal  of  the  specimen  depends  upf)n  the 
topography  of  the  laryngeal  lesion.  If  a  small  growth,  it  should  be  re- 
moved entirely  with  a  goodly  jjortion  of  the  normal  basal  tissues.  If  a 
large  growlh,  and  there  are  objections  to  entire  removal,  the  edge  of  the 
growth  including  apparently  normal  as  well  as  neoplastic  tissue  is  ne- 
cessary.    If  the  larynx  is  the  seat  of  a  diffuse  infiltrative  process  pervad- 


108 


DIRECT   LARYNGOSCOPV. 


ing  nearly  the  whole  larynx  a  specimen  should  be  taken  from  at  least 
two  locations,  preferably  axoiding  the  cords  if  these  are  relatively  slight- 
ly involved.  In  these  diffuse  infiltrations  there  is  always  a  suspicion  of 
])ericlinn(lritis  of  inflammatory,  luetic  or  tuberculous  origin,  therefore  it 
is  often  desirable  to  include  a  bit  of  cartilage  in  the  specimen.  About  the 
only  place  where  it  is  justifiable  (in  probably  benign  cases  I  to  remove 
cartilage  is  from  tiie  epiglottis.  If  the  epiglottis  is  uninvolved  the  ex- 
treme tip  of  the  arytenoid,  or  better  still,  the  cartilage  of  Santorini  or 
of  W'risberg  may  be  removed ;  but  accuracy  is  necessary  here  in  order  not 
to  do  unnecessary  damage  to  the  crico-arytenoid  joint.  After  the  taking 


Fig.  8i. — Schema  of  a  cross  section  of  the  larynx  illustrating  the  outward 
depth  of  the  ventricle,  and  also  the  reason  why  dyspnea  is  usually  inspiratory. 
\',  B,  ventricular  bands.  V,  ventricle.  T,  thyroid  cartilage.  C,  cricoid  cartilage. 
V,  C,  vocal  cords.  In  any  dyspneic  condition  such  as  bilateral  paralysis,  air  pres- 
sure of  attempted  inspiration  acting  upon  the  floor  of  the  ventricle,  V,  will  force 
the  cords  together,  whereas  in  expiration  the  air-flow  upward  has  no  tendency  to 
narrow  the  glottis.  In  removing  growths  from  the  ventricle  the  band,  \',  B,  must 
iie  lifted   (See  Fig.  83). 


of  a  specimen  the  patient  should  be  watched  for  a  few  days,  lest  undue 
reaction  supervene  from  mixed  infections  getting  into  the  wound,  and 
especially  if  potassium  iodid,  which  especially  predisposes  to  acute  edema 
has  been  given.  In  possibly  luetic  cases  a  prompt  report  must  be  urged 
because  of  the  necessity  of  immediate  institution  of  treatment.  In 
malignancy  promptness  is  also  needed.  As  Sir  Felix  Semon  (Bib.  -iD-i) 
has  so  ably  pointed  out,  not  only  should  operation  closely  follow  the  tak- 
ing of  the  specimen;  but  if  the  patient  should  not  agree  beforehand  to 
radical  operation  in  the  event  of  histologic  examination  showing  malig- 
nancy, no  sjiecimen  at  all  should  be  taken  in  cases  which  clinically  seem 


DIRIX'T   LAKY.VCOSCOl'V.  ]  U'J 

quite  certain  to  he  malignant.  Sliouhl  the  since-discovered  effect  of  ra- 
dium in  controHing  malignancy  fulfill  earK  promises,  this  latter  advice, 
sound  in  its  day,  may  require  modification. 

Removal  of  growths  from  the  laryngeal  ventricle,  (irowths  in  the 
ventricle,  especially  when  of  small  size,  may  lie  rendered  exceedingly 
difficult  of  removal  by  the  oxerhanging  projection  of  the  ventricular 
bands,  which,  for  the  time  being,  exaggerates  very  much  the  outward 
depth  of  the  ventricle.  In  such  cases,  general  anesthesia  may  be  required 
and  it  is  ])erfectly  justifiable,  provided  there  is  no  stenosis  whatever,  and 
not  the  slightest  dyspnea.  With  thorough  cocainization.  however,  it  is 
alwavs  possible  to  get  these  growths  by  the  lateral  method  of  operating. 
The  degree  of  overhang  of  the  ventricular  band  especially  when  in  a 
state  of  s[)asm  is  seldom  realized  (Fig.  SI  ),  Where  a  growth  involv- 
ing the  cord  proliably   extends  far  hack   into  the  ventricle,   or  where  a 


B 


Flo.  82. — Pencil  sketch  of  direct  laryngoscopic  view,  sitting  patient,  shuuing, 
at  ]').  a  growth  springing  from  tlie  outermost  depth  of  the  right  ventricle.  At  ■\, 
the  growth  is  hidden  by  the  overhang  of  the  ventricular  hand.  At  C.  the  dntted 
line  indicates  the  growth  under  the  overhanging  ventricular  hand. 


growth  springs  from  the  ventricle  itself  and  is  hidden  by  the  ventricular 
band  as  in  Fig.  82,  it  is  not  necessary  to  pimch  out  the  ventricular  band 
(as  shown  to  have  been  accidentally  done  in  Fig.  80)  in  order  to  expose 
the  flcKjr  of  the  ventricle  and  thus  render  more  accurate  llie  tumor  re- 
mov;d. 

In  such  a  case  as  that  shown  in  Fig.  S'i  the  head  of  the  i)atient  is 
carried  far  over  to  one  side  after  the  larynx  is  exposed  (Fig.  8;?).  If 
the  tube.  E,  has  not  been  passed  at  the  side  of  the  tongue  it  is  now 
slii)])ed  over  to  the  lower  corner  of  the  mouth.  11.  .itid  the  p.itient's  head 
is  tilted  o\er  to  the  same  >ide  wliile  the  o1iser\er  w.'Uclies  thrciugli  the 
tube.  Tile  second  assistant  must  keej)  the  larynx  lixed  and  in  the  ver- 
tical position.  The  tube  is  ;idvanccd  until  the  ventricular  band  is  fiat- 
tened  and  the  growth  can  be  renioxed  from  the  ventricle. 


110 


DIRECT   LARYNGOSCOPY. 


Removal  of  large  benign  tumors  of  the  larynx  above  the  cords. 
The  author  often  uses  for  this  class  of  case  the  alligator  punch  forceps. 
Fig.  36.  They  can  be  inserted  through  the  author's  laryngoscope,  but 
the  best  way  is  by  the  author's  "ex-tubal"  method.  The  forceps  are  in- 
serted alongside  the  laryngoscope,  which  is  used  only  to  look  through 
for  the  accurate  ocular  guidance  of  the  forceps  as  shown  in  the  schema 
Fig.  84.  The  jaws  can  be  placed  and  the  bite  made  with  great  accuracy. 
The  side-slide  laryngoscope   (Fig.  l-"))   because  of  its  oval  lumen  is  pre- 


FiG.  83. — Schema  illustrating  the  lateral  method  of  exposing  a  growth  in  the 
ventricle  of  Morgani,  by  bending  the  patient's  head  to  the  opposite  side  while  the 
second  assistant  externally  fixes  the  larynx  with  his  hand.  M,  patient's  mouth. 
T,  thyroid  cartilage.  R,  right  side,  L,  left.  V,  B,  ventricular  band.  C,  C,  vocal 
cord.  The  circular  drawing  indicates  the  endoscopic  view  obtainalile  by  this  method. 
The  tube,  E,  is  dropped  to  the  corner  of  the  mouth,  B,  and  the  tube  is  inserted 
down  to  R. 


ferred  by  many  operators  some  of  whom  leave  the  slide  oft'.  In  case  of 
still  larger  tumors  with  more  or  less  pedunculated  base  the  heavy  snare, 
Fig.  41,  may  be  used  to  excellent  advantage  by  the  "ex-tubal"'  method. 
In  some  of  the  author's  cases  tumors  the  size  of  a  hen's  egg  have  been 
thus  removed.  Sessile  growths  may  be  removed  by  the  galvano-cautery 
snare,  but  the  author  prefers  forceps.  Of  course,  there  could  be  no 
hope  of  thorough  removal  of  malignancy  by  such  means  ;  and  incom- 
plete removal  is  rarely  if  ever  justifiable. 


DIRKCT    I.ARYNCOSCOrY. 


11] 


Aiiipiitalio)!  of  the  cp'u/lottis  for  palliation  of  dysphagia  in  tuber- 
culosis or  malignant  disease  is  an  operation  easily  performed  and  of 
benefit  where  the  dysjjhagia  is  due  to  ulceration  of  the  epiglottis.  It  is 
possible  that  very  early  malignancy  of  the  extreme  tip  can  be  cured  by 
such  means,  and  the  author  has  had  such  a  successful  result  in  two  in- 
stances. Closure  of  the  air  passages  to  the  entrance  of  food  during  swal- 
lowing seems  to  be  a  three-fold  process.  The  tilting  of  the  larynx  and 
especially  of  the  arytenoids  and  the  arytenoid  a{)proximation  are  prob- 


/^:;:;;>v 


♦•'> 


) 

Fig.  84. — Sclicma  illustrating  removal  nf  a  tumor  from  the  upper  part  of  the 
laryn.K  liy  the  author's  "ex-tuhal"  method  for  large  tumors.  The  large  alligator 
basket  punch  forceps,  F,  is  inserted  from  the  right  corner  of  the  mouth,  and  the 
jaws  are  placed  over  the  tumor,  T,  under  guidance  of  the  eye  looking  through  the 
laryngoscope,  L.  This  method  is  not  used  for  small  tumors.  It  is  excellent  for 
amputation  of  the  epiglottis  viith  these  same  punch  forceps  (Fig.  36)  or  with  the 
heavy  snare.   (Fig.  41.) 


ablv  the  chief  factors.  In  addition  to  this,  however,  there  is  the  closure 
of  the  ventricular  bands  below  and  the  capping  by  the  epiglottis  above. 
The  least  important  of  the  three  seems  to  be  the  epiglottis  and  it  can 
very  readily  be  disjiensed  with  if  necessary  to  relieve  pain  or  cure  dis- 
ease. Probably  its  chief  function  is  to  act  as  a  snow  plow  in  splitting 
the  food  bolus  and  drifting  the  two  portions  laterally  into  the  pyriforin 
sinuses  thus  directing  the  food  bolus  ])ast  the  adilus  laryngis.  Mr.  Wal- 
ter O.  lldwarth  states  that  the  epiglottis  lias  imthini,^  wlialc\or  to  do  will' 


113  DIRECT   LARYNGOSCOPY. 

laryngeal  closure  during  swallowing.  As  a  clinical  fact  we  know  that 
amputation  of  the  epiglottis  is  not  often  followed  hy  serious  .symptoms 
and  results  in  the  relief  of  pain  are  excellent.  Lockard  ( llih.  ;!4G )  has 
collected  statistics  on  the  results  in  tuberculosis.  It  would  not  be  easy 
to  get  out  more  than  the  projecting  part  of  the  normal  epiglottis,  but  it 
is  not  difficult  to  remove  all  of  the  involved  portions.  The  projecting 
part  may  be  amputated  with  the  heavy  snare  shown  in  Fig.  41,  and  this 
is  the  better  way  in  those  rare  cases  of  disease  limited  to  the  tip  be- 
cause of  the  en  masse  removal.  In  more  general  involvement  either  the 
snare  or  the  large  basket  alligator  punch  forceps  ma\-  be  used.  With 
either  instrument  it  is  best  to  operate  by  the  author's  "ex-tuljal"  method 
shown  in  the  schema.  Fig.  84. 

Endolarytujcal  operations  farorhu/  dci'elopwcnt  of  ad:  cntitioits  t'O- 
cal  cords.  In  some  instances  liberation  of  adhesions  will  favor  the  for- 
mation of  adventitious  vocal  cords.  In  other  instances  where  there  is 
tension  from  contraction  of  cicatricial  tissue  hampering  mobilitv  of  the 
arytenoids  an  incision  designed  to  relieve  the  tension  and  supply  a  re- 


FlG.  85. — Autlior's  laryngeal  knife,  30  cm.  long.     Illustruliun  reuruduccd   from 
the  earlier  volume.  ' 

dundancy  of  tissue  for  later  absorption  will  bring  back  the  voice  as  illus- 
trated in  the  case  cited  m  the  section  of  this  work  that  deals  with  papil- 
loma. For  such  incisions  the  author's  laryngeal  knife.  Fig.  8."),  is  ex- 
cellent. The  sharp  anterior  commissure  is  essential  to  good  phonation. 
In  Fig.  15,  Plate  1,  is  illustrated  a  case  in  which  the  action  of  the  laryn- 
geal musculature  was  unable  to  approximate  and  draw  tense  the  adven- 
titious vocal  bands.  The  patient,  a  man  of  thirty  years,  when  convales- 
cent from  a  very  severe  attack  of  typhoid  fever  became  dyspneic  and 
was  tracheotomized  by  Dr.  James  \V.  McFarlane.  When  the  perichon- 
dritis had  subsided  the  larynx  remained  stenosed  by  cicatricial  tissue,  and 
the  case  was  transferred  to  the  author's  service  at  the  Western  Pennsyl- 
vania Hospital  for  decannulation.  The  stenosis  was  cured  by  larvngos- 
tomy  by  the  author's  method  as  described  in  a  later  chapter.  After 
decannulation  and  plastic  closure  the  patient  could  not  speak  louder 
than  a  whisper  because  of  inability  of  the  laryngeal  musculature  to  ap- 
])roximate  and  draw  tense  the  cicatricial  adventitious  vocal  bands  (Fig. 
1-"),  Plate  1  ).  With  a  sliding  punch  forceps  the  author  cleared  the  anterior 
commissure  of  all  tissue  out  to  the  perichondrium,  as  shown  bv  the 
dotted   line,   with    excellent    vocal    results.      In    this    kind   of   case,    it    is 


niRI-CT  LARYNGOSCOPY.  113 

alisoliiteiv  necessary  to  remove  the  tissue  anteriorly  very  radically  but  to 
harm  the  tissue  at  the  sides  as  little  as  possihle.  There  was  a  thick 
redundancy  of  tissue  not  under  tension.  With  a  thin  band-like  web 
under  tension  it  is  usually  better  to  incise  with  the  knife  as  in  the  case 
referred  to  under  "Papilloma." 

Eudosco/'ic  evisceration  of  the  larynx  is  a  procedure  which  will 
cure  a  few  cases  of  cicatricial  laryngeal  stenosis  especially  those  where 
the  cicatrices  are  thin  and  web-like.  Illustrative  cases  are  shown  in 
Plate  1.  Fig.  1  shows  a  post-dijjhtheritic  stenosis  in  a  boy  of  fourteen 
years  admitted  to  the  Western  Pennsylvania  HosjMtal  for  decannulation. 
.\n  incision  was  made  in  the  plane  of  the  glottis,  so  that  the  slide  inuicb- 
forceps  could  be  inserted.  All  of  the  endolaryngeal  tissue  that  could 
be  removed  without  injury  to  the  arytenoid  cartilage  was  extirpated,  the 
efifort  Ijeing  made  to  lay  bare  the  perichondrium  of  the  laryngeal  wall, 
as  shown  schematically  in  Fig.  8(1.  Healing  was  prompt  but  left  a 
slight  recurrence  of  the  cicatricial  tissue  in  the  anterior  commissure. 
Thorough  removal  of  this  with  a  pointed  slide-forceps  was  followed  by 
an  excellent  result  (Fig.  ."),  Plate  1  )  both  as  to  voice  and  cure  of  stenosis. 
He  was  seen  two  years  after  decannulation  and  was  learning  a  trade  in 
a  mill.  A  similar  case  was  that  of  a  man.  aged  40  years,  who  applied  to 
the  Eye  and  Ear  Hospital  Dispensary  for  decannulation.  He  had  been 
tracheotomized  during  typhoid  fever  about  a  vear  before.  The  larynx 
was  occluded  by  a  thin  membranous  cicatrix  which  left  only  a  small 
opening  posteriorly  (Fig.  1,  Plate  1  ).  There  was  slight  arytenoid  move- 
ment on  both  sides.  The  laryn.x  was  eviscerated  as  in  the  previous  case, 
but  required  two  subsecjuent  removals  of  tissue  to  clear  the  anterior 
commissure.  .An  excellent  result  was  uUinialcly  obtained  (Fig.  8,  Plate 
]  )  and  the  [Jatient  was  decannulated  after  two  months'  watching.  The 
voice  was  loud,  though  rough,  and  there  was  no  recurrence  of  the 
dyspnea  when  seen  two  years  later.  In  three  other  cases  the  same  meth- 
od was  not  sufliciently  successful  to  permit  decannulation  but  the  method 
is  well  worthy  of  trial  before  resorting  to  laryngiistf)mv.  .\  simple  punch- 
ing out  of  the  occluding  membrane  is  not  sulTicient.  .\n  effort  should  be 
made  to  remove  all  of  the  tissue  in  the  larynx  clear  out  to  the  perichon- 
drium, but  without  removing  any  part  of  either  arytenoid  cartilage,  in 
non-])aralytic  cases.  In  cases  of  posticus  paralysis  the  excision  may  be 
carried  farther  back,  excising  a  jiortion  of  the  processus  vocalis  of  the 
arytenoids. 

I'oca!  results.     Two  classes  of  cases  must  be  considered. 

1.  In  cases  of  laryngeal  stenosis  in  which  no  air  is  going  through 
the  larynx  on  expiration  with  the  cannula  temporarily  occluded  with  the 
finger,  the  patient  of  course  has  no  voice  except  the  "buccal  voice"  like 


1  I  4  DIRKCT  LARYNGOSCOPY. 

that  developed  by  the  laryngectomized  patient.  These  patients  can  be 
promised  a  good  whispered  voice  immediately  after  operation.  Phona- 
tion  will  depend  on  the  conditions  mentioned  below  in  the  next  class  of 
cases. 

2.  In  cases  of  laryngeal  stenosis  in  which  anv  e.xpiratorv  air  at  all 
is  going  throtigh  the  laryn.x  when  the  tube  is  temporarih-  occluded  with 
the  finger,  the  voice  is  usually  fairly  good.  Therefore,  one  of  the  first 
questions  to  be  considered  is  in  regard  to  the  voice  after  operation.  The 
author  has  demonstrated  that  the  most  important  factor  in  the  produc- 
tion of  an  adventitious  cord,  after  operative  or  morbid  loss  of  the  true 
cord,  is  the  traction  of  the  arytenoid.  The  thousands  of  pulls  dailv  end 
in  a  band  which  more  or  less  perfectly  in  appearance  and  function  re- 
places the  lost  cord.     So  close  is  the  resemblance  in  some  cases  that  ex- 


FiG.  S6. — Schema  showing  endoscopic  evisceration  of  the  laryn.x  for  posticus 
paralysis.  The  attempt  is  made  with  the  shding  punch  forceps  (Fig.  37)  to  eviscer- 
ate all  of  the  laryngeal  tissue  inside  of  the  dotted  line.  It  is  practically  an  impos- 
sibility to  remove  all  of  the  tissue  hut  the  attempt  will  relieve  the  stenosis  in  some 
instances.  In  non-paralytic  conditions  it  is  very  necessary  to  avoid  injuring  the 
arytenoid  cartilages ;  for  in  these  cases  good  arytenoid  mobility  will  assist  in  the 
formation  of  an  adventitious  cord. 


pert  laryngologists  are  unable  to  say  whether  a  cord  is  original  or  ad- 
ventitious. To  get  such  results,  however,  it  is  absolutely  necessary  that 
there  shall  be  mobility  of  the  cricoarytenoid  joint.  Of  course  the  whis- 
pered voice  will  never  be  lost  so  long  as  the  respiratory  air  passes  through 
the  larynx.  The  "stage  whisper,"  for  which  no  cord  is  necessary,  may 
to  be  very  loud,  and  in  soine  instances  the  ventricular  bands  will  approxi- 
mate and  phonate,  but  to  phonate  eft'ectively  requires  a  cord,  natural  or 
adventitious.  The  voice  of  the  ventricular  band  is  deep  and  rough,  and 
lacks  flexibility.  The  ventricular  band,  however,  is  mostly  removed  in 
endolarv-ngeal  evisceration.  From  his  results  with  endolarA'ngeal  eviscera- 
tion, the  author  believes  that,  in  all  forms  of  non-malignant  chronic 
laryngeal  stenosis  a  good  chance  of  a  cure  of  the  stenosis  may  be  prom- 
ised in  any  case  in  which  there  is  not  too  much  loss  of  the  cartilage 
which  maintains  the  patulence  of  the  laryngeal  box.     An  ultimate  good 


niRKCT   I.ARYXCOSCOPV.  11.J 

vuicc  can  be  [jromised  in  all  cases  in  which  there  remains  good  arylenoiil 
mobility.  A  fairly  loud,  though  rough  and  inflexible  voice,  can  be  prom- 
ised in  any  case  without  mobility.  Endolaryngeal  evisceration  should  be 
tried  before  resorting  to  laryngostomy. 

Galvano-cauterizatiou  for  chronic  hypertrophic  laryui/col  stenosis. 
The  author  has  had  e.xcellent  results  from  the  galvano-cauterization  of 
chronic  subglottic  edema  or  hyperplasia  seen  in  children  after  diphtheria. 
In  some  instances  the  children  had  been  intubated  in  others  tracheotom- 
ized  for  dyspnea  during  the  height  of  the  diphtheritic  process.  An  illus- 
trative case  is  shown  in  Fig.  87,  referred  to  the  author  by  Dr.  Torian  for 
extuljation.  A  boy  of  two  years,  after  laryngeal  diphtheria  requiring  in- 
tubation, could  not  be  extubated  because  of  a  recurrence  of  dyspnea 
within  a  few  minutes  of  the  removal  of  the  intuliation  tube.  A  number 
of  attempts  had  been  made  during  two  months.  In  the  recimibent  posi- 
tion the  author  remo\eil  the  intubation  tulie  tlirou.nh  the  direct  laryng(j- 


®®®® 


Fk;.  S7. — IHrt'ct  view.  Recumbent  pcisitimi.  Illustration  ol  the  effectiveness  of 
galvano-cauterization  of  post-diiilitheritic  subglottic  stenosis.  A,  shows  the  larynx 
immediately  after  the  reinoval  of  the  intubation  tube.  B,  five  minutes  later  the 
hyprrtropliic  subglottic  masses  on  each  side  are  seen  to  have  closed  in  like  intumes- 
cent  turbinals.  C,  the  left  mass  has  been  cauterized  and  is  bound  down  by  a  linear 
cicatrix  parallel  with  the  long  axis  of  the  trachea.  D,  shows  the  larynx  after  cure 
by  repeated  cauterizations. 

scope.  A  subglottic  mass  could  be  seen  on  each  side,  biu  an  ample  chink 
was  left  for  breathing,  as  shown  at  A.  Fig.  87.  At  the  end  of  live  min- 
utes the  masses  had  swollen  until  they  almost  met  in  the  median  line  and 
the  child  became  intensely  cyanotic.  A  bronchoscope  was  inserted  and 
left  in  the  trachea  while  a  tracheotomy  was  done.  Later  the  galvano- 
cautery  knife  was  used  to  incise  the  hypertrophic  masses,  one  such  in- 
cision Ijeing  shown  at  C.  .\  perfect  cure  resulted  and  the  child  was  re- 
ported well  six  months  later,  .\notlier  case,  that  of  a  young  child 
tracheotomized  for  diphtheria  three  months  previously,  was  referred  to 
the  author  for  decannulation  by  Dr.  j.  W.  .Mtn-jihy.  Galvano-cauteriza- 
tion of  the  subglottic  hypertrophies,  as  in  the  jireviously  mentioned  case. 


116 


DIRECT  LARYNGOSCOPY. 


resulted  in  a  complete  and  permanent  cnre.  It  was  still  well  a  year  and 
a  half  later.  In  one  case  admitted  to  the  Western  I'ennsylvania  Hospi- 
tal subo^lottic  edema  followed  an  influenzal  tracheitis  for  which  tracheot- 
om\-  had  been  done.  The  same  method  resulted  in  perfect  cure  that 
has  borne  the  test  of  time.  The  method  is  ideal  for  hypertrophic  condi- 
tions, Ijut  is  not  so  well  adapted  to  cicatricial  stenoses,  though  the  au- 
thor had  a  [jartial  result  in  one  case. 

Galvano-cautery  puncture  has  superseded  all  caustics  for  laryngeal 
use.  The  excellent  results  achieved  by  Heryng,  Hajek  and  jMermod 
(Bib.  407)  in  the  galvano-caustic  treatment  of  tuberculosis,  led  the  au- 
thor to  develop  the  endoscopic  technic  and  his  results  have  been  very  sat- 
isfactory. This  plan  of  treatment  has  also  been  advocated  in  an  excellent 
monogra])h  (  Bib.  20)  by  Prof.  Louis  Bar  of  Xice.    The  use  of  the  curette 


Fic.  88. — Direct  view  (sitting  position)  of  a  tnl)crculous  larynx,  in  a  girl  of 
17  years.  The  large  club-shaped  infiltrations  in  the  right  hand  view  were  reduced 
by  three  cauterizations  at  three  weeks'  intervals  to  the  size  shown  on  the  left  hand. 
Slight  sloughing  occurred  near  the  right  arytenoid  (upper  left  quadrant  of  the  left 
circle).    This  is  a  rare  sequel,  and  it  did  ui>  harm. 


and  of  lactic  acid  have  been  quite  generally  abandoned  since  such  abun- 
dant evidence  has  been  forthcoming,  proving  the  great  usefulness  of  the 
galvano-cautery  in  the  treatment  of  tuberculous  infiltrations  in  the  larynx 
and  all  of  the  laryngologists  who  have  used  the  direct  methods  for  these 
apjilications  are  enthusiastic  as  to  the  precision  with  which  the  caustic 
point  can  be  ap[)lied.  The  direct  method  exposes  to  view  the  anterior 
surface  of  the  posterior  wall  of  the  arytenoid  masses,  and  thus  the  point 
can  lie  applied  practically  per[)cndicularly  to  the  surface,  which  is  in 
great  contrast  to  the  indirect  niethod  by  which  a  more  or  less  lateral  ap- 
plication of  the  poiiU  renders  accurate  puncture  more  difficult,  and  some- 
times im])ossible.  I'urthermore,  it  matters  little  how  intolerant  the  pa- 
tient may  be  to  the  laryngoscopic  mirror;  he  cannot  in  any  case  what- 


DIRECT   LAKVNC.OSCOPV.  117 

soever  prevciu  tlie  skillful  oi'eialor  from  makini;  an  accurate  applica- 
tion. Direct  larxngoscopy  has  opened  u\>  a  new  field  in  the  local  treat- 
ment of  tul)erciilcus  lesions.  It  seems  eiptally  well  adapted  to  ulcerative 
and  non-ulcerated  infiltrations.  Of  course,  it  is  sufiject  to  the  same 
general  and  local  contraindications  that  apply  to  any  surgical  treatment 
of  laryngeal  tuberculosis,  especially  the  inadvisability  in  cases  with  ad- 
vanced pulmonary  disease.  In  severely  stenosed  larynges  a  tracheotomy 
should  first  be  done,  for  though  tlic  reaction  is  slight,  it  might  be  sufti- 
cient  to  close  the  narrowed  glottis.  Application  of  the  galvano-cautery 
to  tuberculous  lesions  below  the  larynx  has  been  unsatisfactory  in  the 
author's  hands.  The  technic  is  simple.  The  author  uses  the  electrode 
illustrated  in  his  earlier  work  I  l!ib.  2(i9)  with  hard  rubber  insulation  vul- 
canized onto  the  copjjcr  conductors  insuring  cleanliness.  In  a  few  in- 
stances a  right-angled  point  is  useful  but  usually  the  straight  point  is 
better.  The  larynx  is  anesthetized  locally  and  exposed  with  the  direct 
laryngoscope,  the  patient  sitting.  The  rheostat  having  been  previously 
adjusted  to  heat  the  electrode  to  a  very  nearly  white  heat,  the  circuit 
is  broken  and  the  electrode  is  introduced  cold.  \\  hen  the  point  is  in 
contact  with  the  desired  location  the  current  is  turned  on  and  the  point 
thrust  in  as  deeply  as  desired.  I'sually  it  should  j)enetrate  until  a  firm 
resistance  is  felt ;  but  care  must  be  used  not  to  damage  the  cricoarytenoid 
joint.  The  circuit  is  broken  at  the  instant  of  withdrawal.  Punctures 
should  be  made  as  nearly  [lerpendicular  to  the  surface  as  possible,  so  as 
to  minimize  the  destruction  of  epithelium,  and  to  minimize  the  reaction 
which  is  greater  after  a  broail  suj)erficial  caiUerization.  The  reaction 
is  usually  slight,  a  gray  tibrinous  slough  detaching  itself  in  a  few  days. 
In  one  c;ise  the  author  h.id  rather  extensive  sloughing,  but  it  left  no  bail 
result.  Xo  after-treatment  is  needed.  Cautery-] )unctures  should  be  re- 
I)eated  every  two  or  three  weeks  selecting  a  new  location  each  time 
until   the   desired   residt    is   obtained. 

.Iftcr-iarc.  After  any  endolaryngeal  operation,  cleanliness  of  the 
mouth  must  be  insured  by  brushing  the  teeth  after  taking  food,  anil  by 
the  rinsing  of  the  mouth  with  alcohol  1  part  to  'i  of  water.  If  the  oper- 
ative w'ound  extends  out  of  the  interior  of  the  larynx,  sterile  water  and 
sterile  liquid  food  should  be  given  for  four  days.  \o  local  applications 
are  needed.  Comjilications  should,  of  course,  be  watched  for.  In  all 
cases,  whether  lr;icheotiimized  or  not.  ihe  ]>alient  sliouKl  be  \\;itched  Ijv  :i 
special  tracheal  nurse.  In  cases  not  tracheolomized,  the  |)ossibilitv  of 
laryngeal  dyspnea  sliouhl  be  in  the  mind  of  the  sin-geon  and  the  muse. 
Inspiratory  indrawing  arunnd  the  cl;i\icles,  inspirators  indr.iu  ini;  almve 
the   sternum    ;uid   .'it    the   e|iigaslriinn.   and   a    fiir\\,ird    movement    (if    the 


118  DIRECT   LARYNGOSCOPY. 

chin  at  each  inspiration  are  the  danger  signs  demanding  immediate 
tracheotomy.     Cyanosis  should  not  be  waited  for. 

Complications  during  cndolaryngeal  operation  are  very  rare.  Dysp- 
nea mav  increase  if  the  larynx  is  stenotic  before  ojieration.  and  tracheot- 
omy may  be  required  in  such  cases.  Idiosyncracy  to  cocaine  may  induce 
toxic  symptoms.  The  sight  and  taste  of  blood  may  nauseate  the  pa- 
tient, causing  syncope.  Serious  hemorrhage  could  occur  only  in  a  hemo- 
phile,  and  it  would  be  long  after  the  operation  before  the  loss  of  blood 
would  be  serious.  Injury  to  an  incisor  tooth  can  only  come  from  mis- 
directed eilfort  in  a  false  position.  The  bite-block,  however,  unless  care- 
fully handled  might  damage  a  frail  tooth,  "bridge-work,"  a  capped  tooth, 
or  other  dental  fixture.  The  loss  of  a  portion  of  an  instrument  down 
into  the  air  passage  is  a  complication  to  be  avoided  by  having  well  made 
instruments  and  especially  by  careful  inspection  from  time  to  time. 

Complications  after  cndolaryngeal  operations  are  unusual,  yet  all 
patients  should  be  watched  closely.  Inflammatory  reaction  is  rarely  se- 
vere if  the  aseptic  technic  has  been  without  a  slip.  Cervical  cellulitis 
has  been  known  to  follow  carelessness  in  this  respect.  Edema  of  the 
larynx  occasionally  occurs  and  in  rare  instances  necessitates  tracheot- 
omy. Emphysema  of  the  neck  occurs  \ery  rarely.  It  does  not  require 
treatment  ordinarily;  but  mav  be  treated  in  the  usual  way  if  desired. 
Hemorrhage  sufficient  to  re(|uire  attention,  either  at  operation  or  sub- 
sequently, is  very  rare,  except  in  hemophiles.  Hemorrhage  within  the 
larynx  of  a  hemophile  can  be  stopped  by  packing  a  roll  of  gauze  tightly 
down  into  the  laryn.x  from  above,  if  the  patient  is  tracheotomized ;  and 
if  not,  tracheotomy  should  be  done.  This  was  required  in  one  case  of 
the  author,  that  of  a  hemophile.  Styptics  are  very  objectionable  for 
laryngeal  use,  and  have  been  known  to  set  up  serious  lung  complications. 
Mermod  (Bib.  384)  advises  morphine  subcutaneously. 

DIRECT  L.\RYNGOSCOPV,  ADULT  P.VTIK.NT,  RKCUMUKXT. 

Exposure  of  the  larynx  in  the  recumbent  patient  is  precisely  the 
same  as  in  the  sitting  patient  so  far  as  the  relation  of  the  instrument  to 
the  patient  is  concerned,  and  so  far  as  the  position  of  the  head  and  neck 
of  the  patient  relatively  to  the  patient's  body  is  concerned.  The  manner 
of  grasping  the  handle  of  the  direct  laryngoscope,  however,  varies,  and 
the  endoscopic  image  is  reversed  with  reference  to  the  operator's  eve 
both  in  the  vertical  and  the  horizontal  direction.  What  was  to  the 
operator  the  left  side  of  the  image  now  is  the  right,  and  the  anterior 
commissure  which  before  was  at  the  bottom  of  the  circular  endoscopic 
picture,  is  now  at  tiie  top  of  ihe  circle.     For  this  reasoiL  practice  in  the 


DIRECT   LARYNGOSCOPY. 


119 


sitting  position  is  of  hut  little  avail  and  a  large  amount  of  practice  is 
re<]uired  in  the  recumhent  position,  because  much  of  the  endoscopic  work, 
and  practically  all  of  the  foreign  body  work  in  the  larynx  and  the 
tracheo-bronchial  tree  is,  or  should  be,  done  in  the  recumbent  position. 
The  best  position  for  the  recumbent  patient  is  that  of  Boyce,  as  de- 
scribed in  a  previous  cha|)ter  and  shown  in  Fig.  T"2  with  the  head  raised 
high     and    fully    extended.       I'nder     no     circumstances     during     direct 


Fig.  89. — Direct  laryngoscopy,  recumbent  patient.  The  second  assistant  is  sitting 
holding  the  head  in  the  Boycc  position,  his  left  forearm  on  his  /(•//  thigh,  his  left 
foot  on  a  stool  whose  top  is  65  cm.  lower  than  the  table-top.  His  left  hand  is  on 
the  patient's  sterile-covered  scalp,  the  thinnb  on  the  forehead,  the  fingers  imder  the 
occiput,  making  forced  extension.  The  riylit  forearm  passes  under  the  neck  of  the 
patient,  so  that  the  index  finger  of  the  right  hand  holds  the  bite  block  in  the  left 
corner  of  the  patient's  mouth.  The  operator  stands,  but  may  sit  on  a  stool  of  the 
same  height  as  that  on  which  the  second  assistant  is  sittini;.  .\n  enlarged  view  of 
the  operator's  hands  is  shown  in  Fig.  90. 


larj'pgoscopy   should  the   head   be   allowed   to   hang  over   the   end   of   the 
table  in  the  Rose  position. 

I'efore  a  start  is  made,  everv  detail  ineminiied  luider  the  head  of 
operating  room  organization  >honl(l  have  been  carried  out.  l'",very  in- 
strument that  might  jiossibly  be  needed  shouM  be  sterile  and  ready, 
sponge  holders  armed,  assistants  in  jiosition,  including  those  who  are  to 
hold  the  patient's  arms  and  legs,  as  well  as  the  one  who  holds  the  head 


120 


DIRECT   LAKYNCOSCOPY. 


and  the  other  who  passes  the  needed  instruments.  The  second  assist- 
ant who  holds  the  head,  then  takes  the  sterile  cap,  slips  it  over  the  pa- 
tient's head  until  the  opening  comes  opposite  the  mouth  of  the  patient. 
Then  he  grasps  the  patieiu's  head  and  elevates  it  while  the  unsterile 
nurse  drops  the  head-hoard  or  shortens  down  the  back-board  of  the  Dr. 
French  table,  as  the  case  ma\-  be,  leaving  the  jiatient's  shoulders  as  far  as 
the  ridge  of  the  scapula,  as  well  as  the  head  and  neck  of  the  patient,  out 
in  the  air  supported  bv  the  second  assistant,  who   nnw   raises  the  head 


Fig.  go. — Direct  lar\ngoscopy,  recumbent  patient.  The  laryngoscope  is  held  in 
the  left  hand.  The  first,  second  and  third  fingers  of  the  right  hand  are  used  to 
pull  down  the  uppei  lip  of  the  patient  to  prevent  pinching  the  lip  1)et\vecn  the 
laryngoscope  and  the  teeth.  The  camera  being  above  the  patient  .gives  a  false  im- 
pression of  the  position  of  the  head  and  chest.  The  chest  is  really  very  much  lower 
than  the  head. 


wilh  the  left  hand,  his  thumb  being  on  the  patient's  forehead,  while  the 
right  hand  is  passed  below  the  patient's  neck  so  that  the  thimble  gag  on 
his  first  finger  can  be  inserted  between  the  teeth  at  the  left  side  of  the 
patient's  mouth,  the  second  assistant  being  on  the  right  hand  side  of  the 
patient  (Fig.  89).  The  most  important  part  of  the  procedure  at  this 
point  is  the  high  elevation  of  the  patient's  head.  Under  no  circum- 
stances must  it  at  this  stage  be  jiermitted  to  fall  until  the  vertex  is  lower 
than  the  table  top. 


DIRKCT   LAKYNC.OSIOI'V. 


1-21 


The  introduction  of  the  direct  laryngoscope  and  the  exposure  of  the 
larynx  may  best,  for  clearness  of  description  as  well  as  for  promptness 
and  eft'ectiveness  of  execution,  be  divided  into  two  stages. 

1.  Exposure  and  identification  of  the  epiglottis. 

2.  Elevation  of  the  epiglottis  and  all  the  tissues  attached  to  the 
hyoid  bone  so  as  to  expose  the  larynx  to  direct  view. 

The  tongue  of  the  patient  need  not  be  held  out.  The  patient  is 
sim])ly  told  to  open  his  mouth,  or,  in  the  case  of  general  anesthesia,  the 
mouth  is  opened  and  tlie  bite-block,  Fig.  3!l,  is  inserted.  The  direct  laryn- 
goscope is  grasped,  as  shown  in  Fig.  HO.  which  is  perferable  to  that 
shown  in  Fig.  59.  Absolutely  always  and  in\arialily  the  left  hand  must 
be  used  to  grasp  the  laryngoscope.  If  this  be  not  done,  the  operator  will 
be  seriously  handicapped  when  it  comes  to  passing  a  bronchoscope,  or  to 


Fig.  91. — End  of  first  stage  of  direct  laryngoscopy,  recumbent  adult  patient. 
The  epiglottis  is  e.\posed  by  a  stroni^  lifting  movement  of  ibe  spaUiln  tip  on  the 
tongue  anterior  to  the  epiglottis. 

operate  on  the  larynx,  because  the  right  hand  should  be  free  just  as 
soon  as  it  is  through  with  its  very  im])ortant  duty  of  drawing  the  upper 
lip  toward  the  nose  of  the  patient  in  order  to  prevent  the  lip  getting 
pinclicd  between  the  laryngoscojic  and  the  upper  teeth.  The  laryngoscoiie 
is  passed  into  the  patient's  mouth  posterior  to  the  dorsum  of  the  tongue, 
exactly  in  the  middle  line,  particular  note  being  taken  that  the  patient's 
head  is  exactly  square  with  the  body  :  that  is,  not  deviated  to  either  side. 
nor  rotated.  The  dorsum  of  the  tongue  is  now  pressed  anteriorly,  in 
other  words,  lifted,  in  the  recumbent  position  of  the  i)alient,  until  tlu- 
epiglottis  comes  into  view.  Great  care  mtist  be  taken  not  to  pass  the 
spatular  lip  beyimd  the  epiglottis  in  this  first  stage;  and  it  is  better  to 
elevate  the  dorsum  of  the  tongue  from  time  to  time  in  order  tlial  there 
shall  be  no  danger  of  the  epiglottis  being  overridden.  When  the  epiglot- 
tis is  seen  to  ])roject  into  the  endoscopic  field,  as  shown  in  Fig.  !•] ,  the 
first  stage  is  completed. 


]22  DIRKCT   LARYNGOSCOPY. 

Second  sta(/c.  Tlie  spatular  end  of  the  direct  laryngoscope  is  in- 
serted to  a  distance  of,  on  the  average,  about  1  cm.  and  then  the  larynx 
is  exposed  by  a  motion  that  is  best  described  as  a  suspension  of  the  head 
and  neck  of  the  patient  on  the  tip  of  the  spatular  end  of  the  laryngo- 
scope Fig.  ')■■?.        In  other  words  we  try  to  lift  the  jiatient's  head  with 


Fig.  Q2. — Schema  illustrating  the  technic  of  direct  laryngoscopy  on  the  recum- 
bent patient.  The  motion  is  imparted  to  the  tip  of  the  laryngoscope  as  if  to  lift 
the  patient  by  his  hyoid  bone.  The  portion  of  the  table  to  the  left  of  the  word 
"TABLE"  may  be  dropped  or  not,  but  the  back  of  the  head  must  never  go  lower 
than  here  shown,  for  direct  laryngoscopy.  The  table  may  be  used  as  a  rest  for  the 
operator's  left  elbow  to  take  the  weight  of  the  head.  The  author  prefers  head 
section  of  the  table  dropped.  (Note  that  in  bronchoscopy  and  esophagoscopy  the 
head  section  of  the  table  must  be  dropped,  so  as  to  leave  the  head  and  neck  of  the 
patient  out  in  the  air,  supported  by  the  second  assistant.) 

the  tip  of  the  speculum.  The  assistant,  consequently,  must  not  take  all 
the  weight  of  the  head.  Particular  care  must  be  taken  at  this  stage  not 
to  pry  upon  the  upper  teeth ;  but  rather  to  impart  a  lifting  motion  with 
the  tip  of  the  speculum  without  depressing  the  jiroximal  tubular  orifice. 
If  the  teeth  are  used  as  a  fulcrum,  there  will  be  a  tendency  to  pry  the 
head    downward,    which    is    a    distinct    disadvantage;    because    the    head 


DIRECT   LARYXGOSCOPY. 


133 


should  be  kept  high  as  well  as  extended.  The  view  first  obtained  of  the 
larynx  is,  to  the  beginner,  often  unsatisfactory,  because  the  larynx  is  in 
a  state  of  spasm ;  and  usually  but  little  is  to  be  seen  but  two  rounded 
masses,  and  anterior  to  them  the  ventricular  bands  in  more  or  less  close 
apposition  hiding  the  cords  (Fig.  i)3).  Of  course  in  deep  anesthesia, 
or  often  even  in  the  very  thoroughly  locally  anesthetized  larynx,  this 
spasm  does  not  occur,  and  the  second  stage  at  once  reveals  the  cords 
moving  rhythmically  with  ins])ir,ition  and  expiration.  It  is  customary 
with  some  endoscopists  to  ask  the  jiatient  to  phonate  continuously  in 
order  to  render  more  easy  the  identification  of  the  glottic  chink  and 
vocal  cords.  It  is  very  much  Ijetlcr.  however,  in  the  author's  o])inion, 
to  insist  U])on  the  jjatient   breathing  steadily   and   deeply:  but   the   begin- 


1-ic;.  t).?. — Lndoscopic  view  at  tlie  eiul  ol  the  si-coiul  stage  of  direct  laryngoscopy. 
Recumbent  patient.  Laryn.v  exposed.  Waiting  for  larynx  to  relax  its  spasmodic 
contraction.  A  deep  inspiration  will  then  show  the  cords  beautifully  exposed.  In 
the  full  relaxation  of  deep  anesthesia  this  spasmodic  closure  does  not  exist  and 
the  second  stage  reveals  the  cords  opening  and  closing  rli\  thniirally  with  inspira- 
tion and  expiration. 


ner  should  try  both  ways.  If  his  attention  is  fixed  upon  this  before- 
hand, almost  any  adult  will  keep  on  breathing  if  the  command  is  re- 
peated frequently. 

DifticiiUics  of  dirrcl  laryngoscopy.  'I'he  difficulties  may  be  classi- 
fied under  two  heads:  Those  that  pertain  to  the  patient  and  those  that 
pertain  to  the  operator. 

The  ease  of  exposure  of  the  larynx  varies  within  very  wide  limits 
in  adult  patients.  There  is  very  little  difference  in  children.  A  very 
muscular,  .stout  adult  with  a  short,  thick  neck  and  a  full  row  of  ujiiier 
teeth  will  usually  be  very  much  more  difficnlt  than  will  a  flaccid,  slender 
patient  with  a  long  neck  and  u[)per  teeth  absent,  liut  it  must  be  re- 
membered that  there  is  absolutely  no  patient  whatever,  whose  larynx 
cannot  be  exposed  to  direct  view   with   the  .sole  exception  of  a  i)aticnt 


^ 


12J:  P]RKCT   LARVXGOSCOrv. 

with  ankylosed  jaws,  preventing  the  opening  of  the  muutli.  so  that  while 
the  ease  of  exposure  may  vary  within  wide  hniits,  there  is  none  m  whom 
direct  laryngoscopy  is  impossible. 

Failure  to  expose  the  epiglottis  is  usually  due  to  too  great  haste  to 
enter  the  speculum  all  the  way  down.  The  efforts  should  be  rather  to 
lift  the  tongue  at  its  dorsum  and  gradually  to  slide  the  spatula  down- 
ward so  as  to  get  into  the  glossoepiglottic  fossa.  When  this  is  done,  the 
epiglottis  will  loom  large.  In  some  cases  the  anterior  one-third  of  the 
larynx  does  not  readilv  come  into  view,  because  it  is  drawn  upon  by  the 
elevation  of  the  hyoid  bone.  To  expose  this  anterior  one-third  all  the  way 
to  the  anterior  commissure,  it  is  in  some  cases  necessary  for  an  assist- 
ant other  than  the  one  who  holds  the  head  to  make  counterpressure  on 
the  thyroid  cartilage  externally,  pushing  the  larynx  backward  (downward 
in  the  recumbent  patient).  Either  lateral  wall  can  be  made  prominent, 
and  the  whole  larynx  can  be  fixed.  To  get  the  best  results  from  counter- 
pressure,  it  is  necessary  to  be  careful  that  the  direct  laryngoscope  is  not 
too  deeply  inserted.  It  should  not  be  deeper  than  is  necessary  to  hold 
the  epiglottis.  In  various  laryngeal  operations,  this  counterpressure  by 
an  assistant  trained  to  the  work,  is  of  great  help  to  the  operator  bv  fix- 
ing the  larynx,  turning  it  to  one  side  or  to  the  other,  as  requiretl,  to 
bring  into  view  one  or  the  other  side  of  the  larynx.  Practice  together 
on  the  part  of  the  operator  and  his  assistant,  in  this  respect  as  in  every 
other,  will  produce  results  by  "team  work"  unobtainable  in  any  other 
wa)-.  In  most  instances  the  best  results  are  obtained  by  having  the  as- 
sistant fix  the  thyroid  cartilage  in  a  vertical  position,  while  the  head, 
only,  of  the  patient  is  turned  over  to  the  side  opposite  to  that  on  which 
the  growth  is  located.  This  side  method  of  operating  is  shown  for  the 
sitting  position  in  Fig.  80.  It  is  relatively  the  same  in  the  recumbent 
patient.  After  learning  how,  passing  the  tube  at  the  side  instead  of  over 
the  dorsum  of  the  tongue  will  render  the  most  difficult  case  easy. 

The  difficulties  that  pertain  to  the  operator  himself,  are  chiefly  due 
to  lack  of  practice.  Absolutely  nothing  will  dispense  with  the  necessity 
of  continued  practice,  and  while  much  may  be  done,  as  mentioned  under 
the  head  of  acquiring  skill,  nothing  will  take  the  place  of  frequent  work 
ui)on  the  patient  in  the  recumbent  position.  As  one  of  the  greatest 
difficulties  is  caused  by  the  spasmodic  contractions,  not  onlv  of  the 
laryngeal  muscles,  but  also  of  the  muscles  of  the  neck,  and  especiallv  all 
of  the  muscles  attached  to  the  hyoid  bone,  it  will  be  of  great  assistance 
if  the  operator  can  have  the  advantage  of  acquiring  the  knack  of  ex- 
posure of  the  larynx  first  in  patients  deeply  generally  anesthetized. 

One  of  the  greatest  difficulties  of  the  beginner  is  in  recognizing  the 
landmarks.     We  are   so  accustomed  to  seeing  classical  pictures  of  the 


DIRECT  LARYNGOSCOPY.  133 

laryr.x  during  inspiration,  expiration  and  phonalion,  thai  we  are  quite 
confused  and  discouraged  when  we  do  not  sec  such  a  picture  by  the 
direct  method.  It  must  he  rememhcred,  however,  that  in  proceeding  by  the 
old  inchrect  method,  observation  is  usually  terminated  when  the  patient 
has  very  much  of  spasmodic  contraction  about  the  pharynx  and  larynx, 
while  in  direct  laryngoscopy  these  sjiasmodic  contractions  are  no  bar  to 
a  continuation  of  the  examination;  and  we  must  learn  to  recognize  the 
landmarks  in  the  state  of  a  high  degree  of  spasm.  This,  of  course,  is 
especially  necessary  in  working  without  any  anesthetic,  general  or  local, 
as  in  the  case  of  children.  We  must  therefore  fix  in  our  minds  the 
previously  mentioned  landmarks,  namely,  the  two  rounded  eminences, 
corresponding  to  the  arytenoids.  It  is  only  on  deep  inspiration  that  aity- 
thing  like  a  typical  picture  of  the  larynx  will  be  seen.  Therefore,  we 
must  terminate  our  search  upon  the  identification  of  the  two  rounded 
masses  and  wait  for  the  inspiratory  opening  to  get  a  view  of  the  in- 
terior of  the  larynx.  Herein  consists  one  of  the  great  advantages  of 
w^orking  with  local  anesthesia.  Should  the  patient  be  anesthetized,  though 
not  c|uite  deeply  enough  to  abolish  the  reflexes  about  the  ])harynx  and 
larynx,  and  especially  if  the  patient  has  been  given  chloroform  along 
with  any  of  the  opium  derivatives,  it  is  a  very  serious  risk  to  wait  very 
long  for  the  glottis  to  open,  ijccause  of  the  paralyzing  effect  of  choloro- 
form  and  the  opium  deri\atives  upon  the  respiratory  center.  On  the 
other  hand,  when  a  local  anesthetic  alone  is  being  used,  we  can  safely  wait 
indefinitely  for  the  patient  to  breathe,  meanwhile  telling  him  to  take  a 
deep  breath  and  not  to  hold  it,  and  reassuring  him  that  he  can  get  his 
breath  perfectly  well  if  he  only  will.  It  is  only  in  infants  and  very 
young  cliildren  ih.it  the  injunction  "keep  on  breathing"'  will  not  he  fol- 
lowed promptly  by  an  inspiration,  but  as  these  are  examined  without  any 
anesthetic,  general  or  local,  we  can  wait  indefinitely  for  the  opening  in- 
spiration, excejit   in  very  dyspneic  cases. 

Hlbou'-rrst  ['osltion.  If  the  operator  is  not  strong  in  tin-  wrist 
and  forearm  he  may  exjierience  fatigue  in  holding  the  lar\nx  of  the 
recumbent  ])alient  ex])osed  for  any  length  of  time.  ]>y  this  it  is  not 
meant  that  great  strength  is  re<|uired.  Like  most  similar  procedures 
there  is  more  in  the  knack  than  brute  strength.  If  endurance  is  being 
taxed  the  aiUlii}r's  elbow-rest  position  will  enable  the  operator  to  work 
for  any  length  of  time  that  could  possibly  be  needed  for  an  endolaryn- 
geal  procediue.  The  head  hoard  of  the  table  is  not  dropped  for  this 
position.  If  ;dready  dropjied  the  head  board  is  raised  to  a  level  position. 
The  operator's  left  elbow  rests  on  the  table  beside  the  patient's  head, 
the  head  being  suspended  on  the  tip  of  the  laryngoscope.  The  operator 
sits  on  a  stool  at  the  head  of  the  table  facing  towards  the  patient's  feet. 


126  DIRECT   LARYNGOSCOPY. 

Suspension  hirymjoscopy  devised  by  Prof.  Killian  to  render  direct 
laryngoscopy  in  the  recumbent  position  easier,  will  be  treated  in  a  separ- 
ate chapter  by  the  great  master  himself. 

DIRECT    LARYNGOSCOPY    IN     CHILDREN. 

For  those  who  have  practiced  it,  direct  laryngoscopy  in  children, 
for  diagnosis,  is  a  simple,  easy  matter  requiring  but  a  minute  or  less. 
without  anesthesia,  general  or  local.  On  the  other  hand,  for  the  be- 
ginner it  may  require  twenty  minutes  at  the  end  of  which  time  he  may 
not  have  had  a  good  view  of  the  larynx.  The  procedure  is  easily  learned 
and  for  five  reasons  it  is  an  absolute  necessity  that  every  laryngologist 
be  able  to  make  the  examination  without  any  anesthesia : 

1.  Anesthesia  is  unnecessary. 

2.  It  is  extremely  dangerous  in  dyspneic  patients. 

3.  It  is  inadmissable  in  a  case  which  may  jirove  to  be  diphtheria. 

4.  If  anesthesia  is  to  be  used,  direct  laryngoscopy  will  never  reach 
its  full  degree  of  usefulness,  because  anesthesia  makes  a  major  pro- 
cedure out  of  a  minor. 

5.  There  is  no  more  reason  for  anesthetizing  a  child  to  look  at  its 
larvnx  than  to  anesthetize  it  to  feel  for  adenoids  with  the  finger. 

\\'hate\er  may  be  said  on  the  subject  of  anesthesia  for  bronchos- 
copy and  esophagoscopy  in  children,  no  one  can  deny  that  the  larynx 
of  any  child  can  be  examined  quickly,  painlessl}'  and  satisfactorily  with- 
out anesthesia,  general  or  local.  By  this  it  is  not  meant  that  a  diagnosis 
can  always  be  reached,  but  the  nature  of  dyspnea  or  croupy  cough  can 
almost  always  be  determined.  Seeing  the  larynx  of  an  adult  by  the  in- 
direct method  does  not  always  mean  a  diagnosis.  Cocaine  in  children 
is  dangerous  and  its  application  is  more  of  an  annoyance  than  the  ex- 
amination. This  matter  has  been  more  fully  dealt  with  in  the  chapter 
on  anesthesia.  The  brief  mention  here  is  to  emphasize  a  matter  in 
which  there  has  been  much  misunderstanding  and  many  misleading  state- 
ments. 

In  leaving  the  subject,  the  author  wishes  to  state  that  any  operator 
who  uses  a  general  anesthetic  on  dyspneic  children  will  some  day  re- 
gret it,  because  of  the  death  of  a  child  from  a  needless  procedure.  If 
the  operator  must  have  a  general  anesthetic,  he  should  do  a  preliminarv 
tracheotomy. 

Inslniinents.  For  a  diagnostic  direct  laryngoscopy  in  children  the 
following  are  needed : 

]  child's  direct  laryngoscope. 
1   double  bronchoscopic  battery. 


DIRIX'T    I.ARYNGOSCOl'V.  127 

1  laryngeal  alligator  forceps,  (Mosher's). 

1  bite  block. 
Tracheotomy  instruments. 

These  are  the  bare  necessities.  The  author  prefers  to  prepare  for  a 
bronchoscopy  also,  with  sponge  holders,  sponges  and  bronchoscopic  for- 
ceps complete,  as  will  be  given  on  a  future  page ;  because  very  often  the 
cause  of  the  trouble  may  not  be  found  in  the  larynx  and  not  to  inves- 
tigate the  trachea  leaves  a  doubt.  If  children  be  examined  in  the  re- 
cumbent position  and  fasting  there  will  be  little  trouble  with  secretions, 
consequently  swabs  and  aspirators  will  not  be  absolutely  necessary  for 
mere  diagnostic  examinations  of  the  larynx  only.  On  the  other  hand, 
if  the  child  has  had  food  or  water  w'ithin  four  hours,  fluid  from  the 
stomach  will  be  plentiful.  If  examined  in  the  sitting  position,  which  is 
always  inadvisable  in  children,  there  may  be  much  trouble  from  fluids  over- 
flowing into  the  larynx.  I'nder  no  circumstances  should  the  endoscopist 
start  to  examine  a  case  of  supposed  foreign  body  in  the  lar_\  nx  with  only 
a  laryngoscopic  outfit.  Everytiiing  needed  for  a  direct  laryngoscopy,  bron- 
choscopy and  esophagoscopy  should  be  ready  in  order  to  get  the  intruder 
wherever  it  may  be. 

For  operative  work  on  the  child's  larynx,  such  as  the  removal  of 
papillomata,  we  must  add  to  the  al>o\e  list: 

4  sponge  holders. 

2  dozen  of  !)  mm.  sponges. 
Tissue  forceps. 

Tracheotomy  instruments  are  listed  and  >iioiild  always  be  sterile  and 
ready.  Xot  that  the  procedure  itself  would  ever,  in  any  normal  child, 
render  tracheotomv  necessary  ;  but  so  many  of  the  diseases  for  which 
a  child  is  laryngoscoped  diagnostically  are  stenotic  in  character  that  the 
endoscopist  should  be  prepared  for  a  tracheotom\. 

Direct  lar\'ngoscop\  of  children  as  compared  to  direct  laryiujuscopy 
of  adults.  A  child  is  more  difticult  to  examine  without  anesthesia  than 
the  easiest  of  adults  with  local  anesthesia;  but  there  is  little  difference 
between  one  child  and  another,  and  any  child  is  easier  without  anes- 
thesia than  the  more  difticult  adults  with  good  local  anesthesia.  An>- 
hnni.nn  bein^,  however,  can  be  satisfactorily  laryngoscoped  directly  if  his 
mouth  can  be  o|)ene(l.  In  children,  the  difliculties  of  direct  laryngoscopy 
are  not  increased  by  smallness  of  the  tube,  for  the  lumen  of  the  child's 
laryngoscope  of  the  author's  design,  is  plenty  large  (  1  cm.l.  Tiie  dilti- 
culties  lie  rather  in  liie  very  flexible  ejtiglottis  of  children,  and  the  fact 
that  the  entire  larynx,  though  relatively  higher  than  in  the  adult,  is  more 
movable   an<l    has  a  greater   tendency   to   retreat   downw.ird   during   ex 


128  DIRECT  LARYNGOSCOPV. 

amination  and  thus  witlidraw  the  epiglottis  immediately  after  the  aryte- 
noids are  exposed.  The  larynx  is  drawn  downward  during  normal  in- 
spiration. In  cases  of  dyspnea  the  exaggerated  activity  of  all  the  res- 
piratory musculature  pulls  the  larynx,  and  with  it  the  epiglottis  quite  far 
downward.  During  examination  without  anesthesia  the  child  by  spas- 
modic laryngeal  activity  holds  its  breath  for  a  considerable  period.  Then 
when  it  takes  a  breath,  it  is  a  deep  and  violent  inspiratory  movement 
which  jerks  the  larynx  downward,  pulling  the  epiglottis,  which  is,  at  best, 
"as  slippery  as  an  eel,"  away  from  the  specular  tip.  In  following  this 
elusive  epiglottis  downward  the  endoscopist  is  apt  to  insert  the  speculum 
deeplv  just  at  the  moment  when  expiration  takes  place  with  a  rising 
larynx;  and  thus  the  speculum  goes  behind  the  cricoid,  which,  if  lifted 
strongly  forward  (upward  in  recumbent  patient),  will  shut  ofl"  the 
larvnx  and  the  beginner  will  be  apt  to  quit  bewildered,  possibly  con- 
demning the  direct  method  as  impractical ;  or,  by  shutting  the  larynx  by 
his  forward  lifting  of  the  cricoid,  he  may  cause  respiratory  arrest  and 
then  condemn  the  proceditre  as  dangerous. 

In  direct  examination  of  the  lar\-nx  in  children  it  is  necessary  to  re- 
member that  the  normal  respiratory  movements,  which  are  automatic 
under  the  control  of  the  respiratory  center  in  the  medulla,  are  totally 
obliterated  as  long  as  spasm  of  the  larynx  lasts.  Hence,  we  note  in 
children  examined  without  anesthesia,  that  the  glottis  mav  remain  closed 
for  a  large  portion  of  a  minute's  time.  In  children  wearing  a  tracheo- 
tomic  cannula,  and  hence  not  needing  air  through  the  larynx,  the  spasm 
may  contintie  over  a  minute  or  more.  In  fact,  it  seems  to  the  operator 
who  is  waiting  for  it  to  open,  to  continue  indefinitely. 

Position.  The  recumbent  position,  as  stated  in  a  former  chapter, 
is  the  only  satisfactory  one  for  an  infant  or  small  child,  and  the  author 
prefers  it  for  all  patients  under  about  sixteen  years  of  age  for  the  rea- 
sons given.  In  dyspneic  cases  over-extension  of  the  head  must  be  espe- 
ciall\-  avoided  because  the  traction  on  the  trachea  lengthening  the  trachea 
necessarily  narrows  it,  partly  by  the  elongation  and  partly  bv  the  sec- 
ondary compressions  induced.  Moreover,  e.xcessive  extension  is  un- 
necessar}-  and  if  roughly  applied  can  endanger  the  spine.  It  also  makes 
laryngeal  exposure  more  difficult  in  children.  Only  moderate  extension 
IS  necessary. 

Endoscopic  appearances  of  the  child's  laryn.v.  The  epiglottis  of 
children,  when  seen  with  the  direct  laryngoscope  without  anesthesia,  is 
very  much  more  of  a  reddish  pink  with  less  of  the  vellow  tinge  of  the 
epiglottis  of  the  adult,  especially  the  adult  epiglottis  as  seen  by 
the  mirror  or  ( after  cocainization »  by  the  direct  method. 
The    reason    for   this   color   is,   probably,    the    engorgement   of   the    ves- 


DIRECT   LARYNGOSCOPY.  129 

sels.  Xotwithstanding  the  reddishness  due  to  engorgement,  indivi- 
dual vessels  are  much  less  noticeahle  than  in  the  adult,  part  of  the  dif- 
ference being  anatomic  and  part  being  due,  probably,  to  the  reflex  en- 
gorgement during  examination. 

The  size  and  especially  the  shape  of  the  child's  epiglottis  vary  very 
extensively.  .\s  the  larynx  is  higher,  depressing  (elevating  in  the  recum- 
bent patient  I  the  tongue  strongly  will  sometimes  cause  it  to  project  up- 
ward in  full  view  (  Fig.  1.  Plate  II  ).  Often  it  retreats  (|U!ckly  and  looks 
more  like  Fig.  !).").  It  is  usually  more  curved  laterally  than  in  the  adult 
and  the  lateral  margins  may  curl  backward  until  they  meet  forming  a  cyl- 
inder. 

In  children  the  first  view  that  one  gets  of  the  larynx  is  often 
similar  to  A,  Fig.  94,  where  the  epiglottis  is  seen  curled  up  and  below  it 


Fu;.  g.}. — Direct  larynyoscopic  views  in  chiUlren.  Recumlienl  position.  A. 
Larynx  expo.secl  by  elevation  with  the  spatular  tip  in  the  glossoepiglottic  fossa, 
anterior  to  the  tonKuc.  The  curled  epi.clottis  hides  all  hut  the  two  arytenoid  em- 
inences and  the  glottis  is  spasmodically  closed.  B.  Same  position  glottis  open. 
C.  Congenital  laryngeal  web  in  a  child  simulating  a  neoplasm  when  glottis  is  spas- 
modically dosed.     D.  Same  patient,  deep  inspiration. 


arc  seen  the  arytenoid  eminences,  .\othing  can  be  seen  of  the  cords 
because  the  larynx  is  in  a  state  of  spasm.  The  normal  infantile  epiglottis 
will  ctirl  up  fully  as  much  as  seen  in  this  drawing.  Stronger  traction 
upward  on  ilie  base  of  the  tongue  will  often  expose  the  aryepiglottic 
folds  continuous  v,  ith  the  arytenoid  eminence  posteriorly  and  with  the 
edge  of  the  epiglottis  anteriorly  (!>,  Mg.  91).  Under  these  circum- 
stances, also,  the  cords  may  not  be  seen  because  they  are  covered  by  the 
spasmodic  ckjsure  of  the  n]>per  orifice  of  the  larynx  especialK'  the  ven 
tricular  band.  .\t  tiie  next  inspiration,  liowe\er,  the  cords  will  sejiarate 
and  a  good  view  down  the  trachea  can  often  be  obtained  in  this  way, 
elevating  the  larynx  with  tiie  spatuLar  end  in  the  glossoejjiglottic  fossa 
anterior  to  the  epiglottis.  .As  a  rule,  however,  this  examination  is  not 
so  satisfactory,  and  it  is  Ijctter  to  proceed  at  once,  as  in  the  adult,  after 
identifying  the  epiglottis,  as  at  .\,  iMg.  9."i.  to  insert  the  laryngoscope 
sulliciently  deeper  to  go  posterior  to  the  e]iiglotlis  and  lift   it    I  in  the  re- 


]30  DIRKCT   LARYNCOSCOPV. 

cumbent  position )  strongly  as  if  to  suspend  the  child  by  the  hyoid  bone, 
using  only  the  tip  of  the  spatular  end  on  the  posterior  surface  of  the 
epiglottis.  If  the  epiglottis  slip  away,  the  speculum  must  be  inserted 
slightly  deeper,  but  onlv  enough  to  catch  the  epiglottis,  and  great  care 
should  be  taken  not  to  insert  too  deeply,  as  in  that  case  the  mouth  of  the 
esophagus  will  be  entered  and  no  amount  of  lifting  with  the  tip  will 
expose  the  larvnx,  as  before  explained.  \Mien  properly  exposed  the 
child's  larynx  will  look  ver\-  much  elongated  antero-posteriorly  and  the 
arytenoid  eminences  will  project  upward  and  outward  like  the  arms  of  a 
thick  ^'.  From  the  top  of  the  arms  of  the  \',  the  aryepigluttic  folds 
extend  forward.  The  cords  are  very  much  deeper  down  and  are  only 
visible  on  inspiration.  (C.  Fig.  U-")  which  also  shows  subglottic  papil- 
iomata. )      If   the  larynx   is   lifted  away   from   the  posterior  jiharyngeal 


Fig.  95. — -Direct  laryngoscopic  views  in  children.  A.  Epiglottis.  B.  Gluttis  on 
inspiration,  prevented  from  a  wide  inspiratory  excursion  by  normal  spasm  at  the 
presence  of  the  instrument  in  an  examination  without  anesthesia.  A  few  moments 
later  it  opened  widely,  and  subglottic  papillomata  are  visible  as  shown  at  C. 
D.  Indrawing  of  the  upper  laryngeal  aperture  in  a  moderate  case  of  congenital 
laryngeal  stridor,  in  an  iufnnt  of  11  numths. 

wall  the  \  may  become  a  thick-based  ^".  This  flaring  shape  of  the  up- 
per part  of  the  posterior  commissure  is  best  understood  by  contrasting 
it  with  the  incurved  laryngeal  aperture  seen  in  congenital  laryngeal 
stridor.  (D,  Fig.  !l.") ).  Plate  11  gives  excellent  views  of  the  child's  larynx. 
Siipraglottic  tracheoscopy  and  subglottic  laryngoscopy  in  children. 
Ordinarily  the  subglottic  region  can  be  seen  well  enough  in  children  by 
the  direct  laryngoscopic  method  described  in  this  chapter.  If,  however, 
more  thorough  study  is  desired,  an  excellent  way  to  do  it  without  pass- 
ing a  bronchoscope  into  the  trachea,  as  for  instance  in  a  case  in  which 
there  is  already  slight  subglottic  edema  that  bronchoscopy  wotild  ag- 
gravate, is  by  what  the  author  has  called  "supraglottic  tracheoscopy" 
(Fig.  9(5).  A  short  esoj^hagoscope.  a  tracheoscope,  or  a  bronchoscope 
with  the   distal   end   not   slanted   is   selected   of  a   size   too   large   to   go 


niKKCT  LARYNGOSCOPY.  131 

through  the  glottis.  W  lien  the  mouth  of  such  a  tuhe  is  insertetl  in  the 
upper  orifice  of  the  larynx  (heing  introduced  llirough  the  laryngoscope 
precisely  as  if  doing  a  hronchoscopy  )  it  will  hold  the  \()cal  cords,  ex- 
posing to  view  the  entire  length  of  the  trachea,  the  vocal  cords  showing 
slightly  at  the  edge  of  the  endoscopic  incture.  (Fig.  in;).  It  is  neces- 
sary to  make  slight  pressm-e  on  the  tracheoscope,  which  must  be  too 
large  to  go  through.  This  was  discovered  in  one  of  the  atUhor's  earliest 
cases  of  foreign  liodv.  before  he  had  [lerfected  his  equipment,  auil  the 
only  instrument  available  in  a  distant  city  was  a  short  traeheoscojje  of 
8  mm.  internal  diameter.  .\  safety-pin  was  thus  removed  with  a  hook 
from  tlie  trachea  of  a  twehe  montlis  old  infant  i  I^)ib.  5iil).  'Po  realize 
the  mechanism  of  sujiraglottic  tracheoscopy  it  is  necessary  to  understand 


Fig.  96. — Endoscopic  image  ot)tained  by  supraglottic  tracheoscopy.  A  tracheo- 
scope or  esophagoscope  or  bronchoscope  whose  distal  end  is  not  slanted  and  whose 
diameter  is  too  great  to  go  through  the  glottis  of  the  child  is  inserted  in  the  upper 
orifice  of  the  larynx  which  is  thus  propped  open.  The  widely  spread  cords  arc 
shown  at  the  sides.  This  patient  was  suspected  of  having  subglottic  hypertrophy 
but  on  tracheoscopy  was  found  to  have  a  thymic  compression  stenosis.  A  lateral 
thymic  comi)ression  as  lierc  shown  is  exceedingly  rare.  Usually  this  form  of  com- 
pression is  anteroposterior. 

the  usually  overlooked  dejilli  of  the  larynx  above  the  cords.  It  is 
into  this  funnel  that  the  iube-ni"Ulli  is  inserted.  Supraglottic  traclieos- 
copy  could  be  used  for  the  cauterization  of  subglottic  hypertrophies 
but  direct  laryngoscoijy,  as  elsewhere  explained,  gives  more  lateral  rt)oni 
in  which  to  work.  Supraglottic  tracheoscopy  is  useful  in  ihj  remo\al  of 
long-pedii-led  ^u!it;lottic  growths  that  Hop  ;ibo\e  and  below  the  rmia 
glcittidis. 

Iiu/:r,-rt  Idryiiqoscopy  '^■Ith  tlic  Hays  ph(iryii</(}scof'C.*  The  Mays 
pharyngosco|ic  is  an  instrument  which  can  be  used  either  for  the  ex- 
amination of  the  naso-pharynx  or  the  larynx.  It  is  composed  of  a  small 
telescope   (similar  to  the  cystoscope)   which  is  enclosed  in  a  flat  metal 

•Written  by  l-IaioUl  M.  Hays,  M.  D.  For  further  detnils  the  reader  Is  re- 
ferred to  the  intfrestiiig  articles  of  Hays,  I3ecl<,  Krledcnwald  and  others. 


132  DIRECT  LARYXGOSCOPY. 

sheath,  in  which  run  wires  which  connect  with  small  electric  hulbs  situ- 
ated at  the  distal  end  on  either  side  of  the  prismatic  lens.  At  right  angles 
to  this  tlat  piece  is  a  handle  which  connects  with  the  rheostat. 

The  instrument  is  used  like  a  tongue  depressor  and  for  the  examina- 
tion of  the  larynx  may  be  employed  in  one  of  three  ways. 

(1)  The  distal  end  is  inserted  behind  the  soft  palate  with  the  lens 
turned  up.  The  patient  is  then  told  to  close  the  teeth  and  lips  over  the 
instrument  and  relax  the  muscles  of  the  throat.  ( )ne  thus  obtains  a  view 
of  the  naso-pharynx.  If  the  lens  is  then  turned  either  to  the  right  or  left 
through  a  half  circle  a  view  of  the  larynx  can  be  obtained. 

(2)  The  lens  is  turned  down  instead  of  up  and  the  instrument  in- 
serted until  the  distal  end  almost  touches  the  pharyngeal  wall.  The  mouth 
is  then  closed  as  in  the  first  instance. 

(3)  In  many  instances  a  larger  and  better  view  of  the  larynx  can 
be  obtained  if  the  tongue  is  held  by  the  examiner  in  the  same  way  as  if 
the  laryngeal  mirror  was  going  to  be  used.  The  instrument  is  then  dipped 
down  towards  the  larynx  until  it  is  just  over  and  behind  the  epiglottis. 
An  excellent  view  of  the  larynx  may  be  obtained  in  this  way. 

Operations  on  the  larynx  can  often  be  performed  by  the  indirect 
method,  using  the  pharyngoscope  instead  of  the  mirror.  The  chief  ad- 
vantage of  this  method  is  that  the  operator  does  not  have  to  work  at  right 
angles  to  his  line  of  vision.  In  oiJerating  in  this  way  the  pharyngoscope 
should  be  inserted  laterally  as  in  method  three,  and  the  operative  instru- 
ments from  the  opposite  side  of  the  mouth.  [As  the  instrument  is  of  iixed 
focus,  the  observer  should  wear  his  reading  glasses. — Author.) 


CHAPTER     VIII. 

Suspension  Laryngoscopy. 

A HISl'ORICAI,. 

Over  the  portals  of  the  Anatomical  Institute  at  Freiburg  in  L'.reisgau 
is  written  in  golden  letters:  "^lortui  vivos  docent" — the  dead  are  the 
teachers  of  the  living.  This  expression  may  likewise  be  applied  to  sus- 
pension-laryngoscopy.  which  originated  in  the  Freiburg  .\natomical  In- 
stitute as  a  result  of  observations  on  the  cadaver. 

In  the  winter  ni  T.Mi!i-l(i  I  had  my  artist  there  produce  the  picture 
obtained  by  direct  laryngoscojjy  upon  the  cadaver.  I  utilized  the  old 
broad  Kirstein  spatula  on  an  electric  handle  and  introduced  it  with  the 
head  pendant.  .\s  1  did  not  have  the  time  to  hold  the  instrument  until 
the  artist  had  com])leted  his  picture  I  improvised  a  fixation-apparatus 
with  several  iron  rods  which  were  attached  to  the  dissecting  table.  1 
attached  the  handle  to  the  rods.  Thus  the  head  of  the  cadaver  hung 
suspended  from  the  mouth-siiatula.  The  mouth  was  forced  widely 
oi)en.  The  teetii  of  the  upper  jaw  were  missing.  I  had  a  comprehensive 
view  into  the  depths  and  was  astonished  at  the  excellent  birds-eye  view 
of  the  entire  topographical  relationship  of  the  mouth  and  pharyngeal 
cavit}',  as  well  as  of  the  larynx  obtained  at  one  glance.  I  was  even  able 
to  see  into  the  hypo])harynx  and,  as  the  larjMix  was  raised  from  the 
vertebral  column,  through  the  eso])hageal  opening  into  the  esophagus. 
The  situation  was  about  as  discernible  as  in  I-'ig.  !•?.  Laterally  from  the 
broad  tongue-spatula  the  tongue  arches.  We  recognize  the  posterior 
pharyngeal  wall  from  the  uvula  to  the  esophageal  opening  in  its  entire 
length  and  breadth.  In  tlie  depth  the  large  cornua  of  the  hyoid  bone 
project  on  the  right  and  left.  The  posterior  surface  of  the  larynx  is 
visible  in  its  entire  area.  Of  the  laryngeal  cavity  the  posterior  surface  is 
particularly  well  seen.  Only  the  anterior  sections  of  the  vocal  cords  are 
invisible. 


•K.speciaUy    written    hy    Prof.    Killiaii    fur-    tlii.^    bunk.      Tianslati'd    by    J.    A. 
Hageman.  M.  D. 


134 


SUSPENSION    LARVXCOSCOPY. 


This  experience  set  me  to  thinking.  It  showed  me  how  one  must 
proceed  to  obtain  a  broad  entry  to  the  depths  of  the  neck.  It  pointed 
a  way  to  the  fulfilhnent  of  a  wish  I  had  long  liarbored — to  find  a  broad 
entrance  to  the  laryngeal  cavity  in  order  to  operate  there  as  gynecolo- 
gists do  in  their  field.  LUit  there  was  still  a  long  journey  to  the  suc- 
cessful consummation  of  the  procedure  upon  the  living.  At  first  I  deemed 
profound  narcosis  absolutely  essential  in  order  to  relax  the  parts  as 
thoroughly  as  in  the  cadaver.  As  sufficient  opportunity  to  narcotize  pa- 
tients for  such  purpose  was  not  afforded.  I  made  no  progress.     During 


i-ig-  97- 

the  following  winter  I  therefore  proceeded  to  practice  upon  two  clinic 
patients  using  only  cocaine.  These  experiments  gave  me  opportunity  to 
construct  a  fitting  instrumentarium.  thereby  consuming  much  time.  Not 
until  the  fall  of  fStf]  had  I  made  sufficient  progress  to  enable  me  to 
issue  a  statement  at  the  International  Laryngological  Congress  in  I'.erlin 
concerning  suspension-laryngoscopy. 

The  time  was  very  opportune  for  the  further  elaboration  of  the 
method  because  of  my  appointment  as  Director  of  the  Berlin  Lar}-ngo- 
logical  Polyclinic.  There  I  had  sufficient  material  at  my  disposal  to 
elaborate  the  new  procedure  jM-actically  in  all  its  miiuitiae.  New  instru- 


SrSl'EN'SIOX    LAKVNGOSCOl'Y.  135 

meiils  were  constantly  constructed,  altered  or  abandoned.     Now  I  have 
nnally  reached  the  point  where  I  can  regard  the  method  as  matured. 

Since  then  I  have  spoken  and  written  about  suspension-laryngoscopy. 
and  have  often  demonstrated  it.  The  procedure  has  been  used  by  my 
pupils,  Alhrecht  and  Hoelscher.  and  also  by  Brieger  and  Seift'ert,  Wolff, 
Hinsberg  and  Kleestadt.  Gerbcr  and  Henke,  Lautenschlaeger,  Storat, 
Kahler.  Katzenstein,  Hopmann  and  Froning,  Chiari.  Steiner,  Pollat- 
scheck.  Simoleki,  Davis  and  Howarth.  Freudenthal,  Iglauer.  Through 
their  collaboration  the  method  has  attained  great  clinical  importance. 

B — I X  SIR  I  ■  M  !■:  X  TS. 

\\'hoever  desires  to  familiarize  himself  with  suspension-laryngoscopy 
must  primarily  know  the  instrumentarium  thoroughly.  I  therefore  be- 
gin with  a  description  of  them. 

] — THli  OPi:u.\Tl.\G  T.ABLIv. 

As  this  method  is  frecjuenlly  used,  it  is  desirable  to  have  an  oper- 
ating table  ijarticnlarly  suited  to  this  purpose.  It  should  have  qualities 
which  make  it  most  practical  for  the  execution  of  direct  examination, 
and  if  possible,  should  be  convenient  for  the  numerous  operations  nowa- 
days ]jcrformed  in  laryngology  and  rliinolog\-.  1  have,  therefore,  con- 
structed a  new  tabic.* 

It  seems  desirable  that  the  operator  should  be  able  to  adjust  the 
table  itself  or  at  least  to  change  its  position.  For  this  reason  all  cranks 
were  aflixed  to  the  head-end  of  the  table.  I  have  always  found  it  very 
uncomfortable  to  sit  on  a  stool  or  kneel  and  assume  a  stooped  position 
while  using  the  ordinary  operating-table.  It  is  verv  exhausting.  Direct 
examination  should  be  made  while  sitting  on  a  chair,  or  while  standing. 
Therefore  the  operating-table  should  be  so  constructed  that  it  can  be 
sufficiently  elevated  by  means  of  a  screw.  Kahler  has  already  built  such 
a  table  for  the  X'ienna  Laryngological  Clinic.  Mine  is  somewhat  simpler; 
by  means  of  a  screw  one  can  elevate  it  as  much  as  desired.  Besides,  it 
is  so  arranged  that  one  can  securely  attach  the  suspension-appliance.  1 
have  likewise  attached  a  separate  supporting-apparatus  for  the  head. 
Further  jiarticulars  may  be  gleaned  from  Figs.  i'S,  9!)  and  loii.  Fig.  98 
shows  tiie  table  in  ordinary  position,  Fig.  !i!t  in  high  ])Osition.  In  Fig. 
100  one  sees  it  from  the  head-end  together  with  the  various  screws  by 
means  of  which  the  changes  of  position  are  made.  I  need  not  dilate 
ui)on  the  minutiae  of  construction.  These  are  based  upon  simple  prin- 
ciples and  are  evident  in  practical  u.se. 

•All  the  In.struments  here  minutely  Jesciibed  may  be  obtiilncfl  friim  the  liims 
Windier,   in  P.erlin.  and  Fi.^cher.  in  Freibui's;  I.  Dr. 


136 


SUSPENSION  LARYNGOSCOPY. 


2 — THE   GALLOWS. 

The  gallows  is  intended  to  provide  a  suitable  suspension-point.  I 
have  used  it  as  it  stands  now,  for  two  years  without  altering  it  in  any 
way.  It  essentially  consists  of  a  column  (Fig.  G)  bearing  a  horizontal 
arm  (a).  The  arm  extends  to  the  middle  of  the  operating-table.  It 
may  be  fixed  higher  or  lower,  forward  or  backward.  The  elevation  is 
chiefly  adjusted  by  transposing  the  column.  In  addition  the  horizontal 
arm  may  be  changed  20  cm.  within  the  column.     The  forward  and  back- 


FiS.  g8. 


ward  motion  of  the  entire  contrivance  is  accom])lished  by  means  of  a 
screw  (b)  (compare  Figs.  101  and  102).  The  gallows  is  screwed  to  the 
operating-table  on  the  right  in  the  maimer  shown  in  Figs.  99  and  116. 


'^ — THE  SUSPENSION- 1 1 01  IK. 

The  suspension-hook  was  formerly  more  sim])le  in  form.  It  con- 
sisted of  a  straight  rod  which  was  curved  at  the  ujtper  end  in  the  form 
of  a  hook.  (Fig.  103  and  104).  Compare  my  essay  in  "Archiv  fi'tr 
Laryngologie,"  Vol.  3G,  1912.  According  to  Albrecht's  investigations, 
however,  it  was  found  necessary  to  put  a  joint  in  the  rod  (compare  Fig. 
104a).  Within  this  joint  a  backward  turning  of  the  hook  takes  place 
about  a  horizontal  axis  (compare  Fig.  106).     This  movement  is  accom- 


SUSPENSION  LAKYNC.OSCOl'Y. 


137 


plished  when  one  turns  the  thumb-screw  clockwise.  In  this  manner  the 
hook  may  he  turned  almost  to  a  horizontal  ])Osition.  The  mechanism  is 
based  upon  the  principle  of  the  endless  screw.  The  portion  helow 
the  joint  shows  several  peculiarities.  The  rectangular  caxitv  (e)  con- 
tains the  screw.  (Fig.  lO.'jf).  The  tongue-spatulas  are  attached  to  the 
pegs  (g).  The  screw  (h)  holds  the  epiglottis-spatula.  .\n  attachment 
which  holds  the  mouth  open,  a  sort  of  mouth-gag  also  is  supplementary 
to  the  suspension-hook  (compare  Fig.  10.5).  It  is  provided  with  a  tooth- 
plate  (k)  which  rests  against  the  upper  incisors.    This  tooth-plate  is  so 


arranged,  (i.autcnschlacger ).  that  it  may  be  extended  or  shortened.  This 
is  accomplished  by  means  of  the  screw  (h).  The  screw-end  of  the 
liandle  is  inserted  into  the  part  (d)  of  the  hook-si)atula,  and  is  securely 
fixed  there  by  means  of  the  screw  (f)  as  shcjwn  in  h'ig.  ]0().  By  turn- 
ing the  screw  (f)  the  handle  (!)  may  be  variously  placed.  In  this  man- 
ner the  patient's  mouth  may  be  opened  as  wide  as  seems  desirable. 


4 — Till-  TONC.ui:-sp.\rri..\. 

The  tongue-spatula  has  in  the  course  of  lime  undergniie  many  modi- 
fications, but  we  now  possess  a  model  which  meets  all  demands.  In 
its  construction  1  have  adopted  the  alterations  wliich  Albrecht  proposed. 


138 


SUSPEXSIOX  LARVNGOSCOPV. 


Figs.  100,  loi,  102,  104,  105,  106,  107,  loS,  100.  no. 


SUSPENSION  LARYNGOSCOPY. 


139 


Figs.  Ill   to  1 1 6. 


140 


SUSPENSION  LARYNGOSCOPY. 


Of  late  a  series  of  details  were  added.  The  tongue-spatula  must  be  a 
simple  instrument  which  has  a  peculiarly  formed  handle  for  attachment 
to  the  suspension-hook,  (m)  Fig.  107  ;  the  upper  surface  which  is  di- 
rected toward  the  tongue  is  rough  (Fig.  107n),  so  that  the  spatula  will 
not  slip  off.  Its  anterior  end  is  heart-shaped  after  the  model  of  the 
Reichert  hook  for  raising  the  epiglottis  (Fig.  ll'J).  On  the  free  sur- 
face of  the  tongue-spatula  one  observes  a  gutter   (o).     Into  this  gutter 


is  placed  a  second  smaller  spatula,  by  means  of  which  the  epiglottis  is 
raised,  the  epiglottis-spatula  (p)  Fig.  108.  It  is  inserted  through  a 
groove.  Fig.  108.  If  the  patient's  tongue  wells  up  to  the  right  and  left 
of  the  spatula,  it  hinders  vision  into  the  depths  of  the  neck.  I  there- 
fore have  recently  had  two  movable  lateral  wings  attached  to  the  tongue- 
spatula  (r)  (Fig.  109  and  Fig.  110).  These  wings  may  be  turned  by 
means  of  a  key  (Fig.  109r)   and   (Fig.  109  and  Fig.  110)   fixed  in  any 


SUSPENSION  LARYNGOSCOPY. 


141 


position.  The  key  (s)  is  removed  after  the  fi.xation  of  the  plates.  In 
Fig.  108  we  see  the  tongue-spatula  in  connection  with  the  epiglottis- 
spatula.  Tn  Fig.  Ill  the  tongue-spatula  is  attached  to  the  suspension- 
hook.  In  J'"ig.  112  we  see  the  tongue-spatula  on  the  suspension-hook 
with  the  epiglottis-spatula  as  seen  from  the  side.  Fig.  113  shows  a 
froiU  \iew  of  the  same. 


5 TH K  COUNTICR-PRESSOR. 


In  order  to  hring  the  anterior  portions  of  the  larynx  within  the  range 
of  \ision  it  often  hccomes  necessary  to  exert  pressure  externally  against 


Fi.?.  1 1". 


the  cricoid  cartilage.  This  requires  the  aid  of  an  assistant.  Tn  order  to 
obviate  this,  .Mhrecht  has  attached  the  Briinings  counter-pressor  to  his 
instrument.  I  have  constructed  a  counter-pressor  upon  new  principles 
(Fig.  III).  It  consists  of  two  parts,  t  and  t,  which  can  be  telescoped 
into  each  other,  and  may  thus  be  lengthened  or  shortened.  It  may  also 
be  turned  ui)on  a  horizontal  axis  at  u.  It  is  attached  to  the  portion  of 
the  suspension-hook  directly  over  the  screw  (Fig  llo).  After  the  sus- 
pension-hook is  connected  with  all  its  supplementary  instruments  it  is 
suspended  from  the  gallows  as  shown  in  Fig.  llC  In  this  position  it  is 
used  during  suspcnsion-laryngoscopy.  Whoever  desires  to  make  the 
examination  successfully  must  first  familiarize  himself  with  the  minutiae 
of  my  construction.  Only  in  this  manner  is  it  possible  to  utilize  all  its 
advantages.    The  whole  arrangement  may  apjicar  somewhat  complicated. 


142  Sl'SPEXSION    LARYNGOSCOPY. 

These  com])Iications,  however,  are  necessary   to   ensure   ihe  best  condi- 
tions for  the  prompt  engagement  of  the  larynx. 

(i — THE  ILLUXIIN.^TION. 

In  laryngoscopical  work  the  month  ami  pharyngeal  ca\ity  are  il- 
luminated in  the  usual  manner.  (Jne  ma_\-  use  the  head-mirror  in  con- 
nection with  a  good  electric  or  gas  lamp.  I  usually  use  the  Kirstein 
head-lamp  (Fig.  117).  For  demonstration  purposes  it  is  fouinl  very 
satisfactory  to  vise  a  diminutive  electric  lamp  whose  light  is  concentrated 
by  means  of  a  lens  attaching  the  light  to  the  tooth-plate  of  the  suspen- 
sion-hook by  means  of  a  clamp.  (Compare  Figs.  122  and  12.'5,  Plate  IV). 

7— -Tll!-;  PERFORMING  OF   SUSPKNSIOX-L.VRVNCOSCOPV. 

Not  every  patient  is  adapted  for  the  performance  of  suspension- 
laryngoscopy.  All  patients  presenting  difficulties  during  the  use  of  the 
direct  method  are  difficult  to  examine  in  the  herein  described  manner, 
and  it  may  prove  impossible  to  do  so  at  all.  Generally  speaking  the  num- 
ber of  such  cases  is  small.  In  children  one  practically  never  meets  with 
difficulties.  In  order  to  ascertain  in  advance  if  the  patient  can  be  com- 
fortably examined,  it  is  advisable  to  attem])t  a  direct  examination  of  the 
larynx  with  the  simple  Kirstein  spatula,  lly  this  means  one  recognizes 
how  far  the  tongue  may  be  sup[>ressed  and  the  larynx  engaged. 

PRi;r.\R.\Tiox  01-  Tin-:  p.\tient. 

Adults  who  are  adaptable  for  the  direct  examination  can  be  exam- 
ined by  means  of  suspension-laryngoscopy,  using  cocaine  .solely,  although 
as  a  rule  it  is  wise  to  administer  a  morphine  injection  ( O.Ol-O.fll.-))  half 
an  hour  previously. 

If  one  contemplates  doing  an  operation  which  may  C(jnsnme  more 
time  and  may  possibly  cause  pain,  it  is  better  to  make  use  of  the  mor- 
phine-scopolamine  narcosis.  Scopolamine  is  lately  furnished  by  the  firm 
HofTmann-I,a  Roche  &  Co.,  in  Crenzach  (1  laden  t  in  permanent  form 
under  the  name  "sko])olamine  haltbar,  Roche."  Three  decimilligrams  are 
hermetically  enclosed  in  a  small  glass  ampoule.  This  is  the  most  suitable 
dose  for  our  pur])0ses. 

The  best  [irocedure  is  to  administer  to  the  patient  two  hours  lie- 
fore  the  suspension-laryngoscopy  0.01  gm.  morphine  and  .(U)i)'.>  dcmgm. 
scopolamine  hy])odermically.  (Jne  hour  later  the  same  (iuantit\-  of  both 
substances  is  again  administered.  The  patient  must  recline  in  a  quiet 
place,  so  that  he  will  go  to  sleep.  In  most  cases  the  numbing  is  only  in- 
complete.    I'liit  the  patient  is  in  such  condition  that  he  undergoes  the  ex- 


SrSPlCNSION    I.AKVNC.OSCOl'Y. 


143 


amination  witliout  resistance  and  also  bears  it  longer.  It  is  necessary,  too, 
to  pencil  (he  larynx  with  cocaine  before  using  the  s])atula.  The  reflex- 
irritability  of  the  pharyngeal  and  laryngeal  mucous  membrane  is  not 
entirely  eliminated  by  the  morphine  and  scopolamine. 

Children  and  young  persons  must  not  receive  any  nmrphine-scopo- 
lamine.  In  childhood  it  is  best  to  use  ether  or  chloroform  narcosis  or  a 
mixture  of  both.  It  is  i>referable  to  use  the  llraun  insufflation-apparatus, 
because  wi'h  it  one  more  rapidly  attains  a  sufficiently  profound  narcosis, 
and  above  all,  because  the  narcosis  can  easily  be  maintained  sufficiently 
profound  during  the  manipulation  in  the  neck.  (Fig.  11!)).  To  hold,  a 
mask  before  the  face  from  time  to  time  during  the  examination  causes 


1       _1^ 


Fig.  liS 


too  much  interrnjition.  Uul  when  one  forces  llu'  clhcr  nv  chlorolunn  in- 
to the  de])ths  with  the  insufflator  as  nuich  will  be  inhaled  as  is  re(|uired 
to  maintain  an  ecjuable,  deep  narcosis. 

In  children,  too,  it  is  to  be  recommended  to  pencil  ihe  larynx  with 
cocaine,  lly  cocainizing,  one  avoids  the  reflex  interference  with  breath- 
ing which  occurs  in  some  cases  when  one  touches  the  interior  of  the 
larynx  with  an  instrument.  I  generallx'  use  the  laryngeal  mirror  and 
the  Kirstein  head-lam])  when  ])enciling  llie  larynx  in  a<hills  and  chil- 
dren. If  til'.'  larynx  cannot  readily  be  approached  the  lower  jaw  is 
pidlcd  forward  or  the  Reiclurt  book  is  inserted  at  the  lingual  base  and 
the  base  of  the  tongue  and  ihe  larynx  are  pulled  forward  by  this  means. 
(Fig.  110). 


144 


SUSPENSION  LARYNGOSCOPY. 


THE  PREPARATION  OF  THE  SUSPENSION-HOOK. 

Preceding  the  introduction  a  tongue-spatula  of  suitable  length  must 
be  selected — Kahler  determines  the  length  by  means  of  a  graduated  Kir- 
stein  spatula  (Fig.  1"'0  ) — and  connected  with  the  suspension-hook.  The 
handle  with  the  tooth-plate  is  inserted  in  such  manner  that  the  mouth 
is  forced  open  only  slightly.  The  counter-pressor  is  folded  upward.  In 
addition  it  is  necessary  to  move  the  hook  so  far  backwards  by  means  of 
the  thumb-screw  that  its  end  comes  to  lie  perpendicularly  above  the  end 
of  the  tongue-spatula.     In  this  form  the  instrument  is  introduced. 


Fig.  1 19. 


%nai6r. 


w 


Fig.  120. 


Before  introducing  the  tongue-spatula  the  patient  must  be  put  in 
the  proper  position.  The  body  is  drawn  so  far  upward  that  the  head 
extends  freely  above  the  edge  of  the  operating-table  and  can  readily 
be  lowered.  At  the  same  time  an  assistant  holds  the  head  in  a  slightly 
lowered  position. 

INTRODUCTION    OF   THE  TONGUE-SPATULA. 

Formerly  I  always  used  a  special  mouth-gag  and  had  the  tongue 
held  with  a  forceps.  Lately  I  avoid  both  whenever  possible.  As  Seifert 
has  demonstrated  the  mouth-gag  or  tongue-forceps  is  not  essential.  It 
is,  however,  advisable  when  introducing  the  spatula  to  some  depth  to 
have  the  tip  of  the  tongue  held,  so  that  the  spatula  may  not  push  the 
tongue  too   tar   into   the  depths. 


SUSPENSION  LARYNGOSCOPY. 


145 


Under  illumination  with  the  Kirstein  head-lamp  the  spatula  is  in- 
troduced against  the  posterior  jiharyngeal  wall  and  then  downward  along 
this  wall  between  epiglottis  and  base  of  tongue.  The  base  of  the  tongue 
is  forced  upward  as  much  as  possible,  and  the  gallows  is  now  so  installed 
that  the  hook  can  be  suspended  from  it.  If  one  has  been  successful  in 
this,  the  assistant  gradually  releases  the  patient's  head,  so  that  its  whole 
weight  presses  upon  the  tongue-spatula. 


In  most  cases  the  interior  of  the  larynx  does  not  yet  become  visible 
in  this  position,  the  ipigloltis  covers  it  almost  entirely.  To  elevate  this 
the  ejiiglottis-spatula  is  rei|uire(l. 

As  already  slated  abo\e.  the  c[)iglottis-spatula  is  inserted  through 
the  groove  in  the  tonguc-si)alula.  and  jiushcd  iiUo  the  depths  under  the 
epiglottis  as   far  as  possible.     Then   one  elevates  the  epiglottis   with   it 


146  SUSPEXPIOX    LARYNGOSCOPY. 

and  secures  the  epiglottis-spatula  with  the  screw.  After  this  procedure  the 
ar\-tenoid  region  and  the  posterior  laryngeal  wall  ordinarily  come  into 
view.  It  now  becomes  essential  to  accomplish  the  finer  adjustment,  so  that 
the  anterior  portion  of  the  larynx  may  also  be  seen.  For  this  purpose  we 
turn  the  thumb-screw  clockwise,  so  that  the  hook  drops  even  lower. 
Should  this  not  prove  sufficient  one  may  press  upon  the  cricoid  cartilage 
with  a  finger,  or  accomplish  this  ])ressure  with  the  counter-pressor  by 
adjusting  and  fixing  it  at  the  proper  spot.  Now  it  is  also  time  to  re- 
move the  handle  with  the  tooth-plate  somewhat  farther  from  the  tongue- 
spatula  and  thereby  force  the  mouth  open  as  wide  as  possible.  This 
is  accomplished  bv  turning  the  large  screw   (f)    (Fig.  lOd). 

If  one  has  been  successful  in  this  manipulation  the  interior  of  the 
pharyngeal  cavity  must,  with  good  ilhimination,  lie  in  full  view.  The 
patient  is  then  in  a  position  as  shown  in  Fig.  1>'1.  The  head  hangs  free- 
ly suspended  from  the  tongue-spatula  :  the  mouth  is  held  open  by  the 
handle  with  the  tooth-plate.  The  portion  of  the  hook  bearing  the  screw 
extends  approximately  in  a  perpendicular  position.  The  hook  itself  is 
turned  sharply  backward  and  so  is  suspended  from  the  gallows.  One 
sees  the  larynx  as  in  Figs.  123  and  123,  Plate  IV. 

D — DEM0NSTR.\TI0X   I.X    SUSPEXSK.IX   L.\KYXGOSC()PY. 

The  new  method  is  particularly  adapted  for  demonstration.  If 
the  pharynx  and  larynx  are  engaged  the  demonstrator  has  nothing  to  do 
but  make  the  necessary  explanations.  The  pupil  readily  grasps  the  sub- 
ject because  he  sees  the  parts  directlv  before  him.  As  above  mentioned, 
it  is  best  for  such  demonstrations  to  use  a  miniature  electric  lamp  at- 
tached to  the  toothplate  of  the  instrument.  When  the  lar_\nx  is  engaged 
during  suspension  laryngoscopy  it  is  very  easy  to  manipulate  its  interior. 
One  can  demonstrate  this  to  the  pupil  by  putting  a  probe  in  his  hand 
and  having  him  touch  designated  points. 

Minor  operations,  for  instance  the  removal  of  a  polyp,  can  be  dem- 
onstrated without  much  trouble.  If  the  ])atient  is  under  skopolamine- 
morphine  "twilight  sleep,"  the  demonstration  may  be  made,  without 
hesitation  to  a  very  great  number  of  physicians  and  students. 

E — CLINIC. \I.    KXPKRIKNCKS    WITH    SUSPEXSIOX-L.VRVXCOSCOPY. 

Suspension-laryngoscopy  has  been  successfullv  applied  in  practice 
both  in  diagnostic  and  therapeutic  respect  by  my  jjupils  and  b\-  me  as 
well  as  by  a  list  of  authors.  It  is  used  diagnostically  especially  in  child- 
hood and  particularly  in  all  those  cases  where  we  are  comjjelled  to  re- 
sort to  direct  examinations.  Its  execution  is  so  simple  that  I  believe 
it  will  soon  replace  direct  laryngoscopy.    We  often  have  occasion  to  make 


SrSI'K.NSIIlX    l..\U>\('.0SCO['Y. 


147 


minute  examination  nnder  narcosis  in  voc-ai  and  resjiiratory  distnrliances 
in  oliildrcn.  One  mnst  determine  if  there  exist  a  simple  iciite  catarrh, 
a  sub-glottic  swelling,  a  croupous  or  di[)iulieritic  process  with  forma- 
tion of  pseudo-membrane,  a  jierichondritis.  or  if  there  be  a  foreign  body 
present  whether  there  be  a  chronic  laryngitis,  formation  of  nodules  on 
the   vocal    cords,    papillomata,    tuberculosis   or   syphilis.      ICven    cases   of 


dit'licult  decanulement  or  congenital  changes  in  the  lar>n\  may  be  con- 
veniently examined  in  su.spension.  1  sliould  like  even  at  this  stage,  to 
recommend  this  procedure  as  a  preparatory  step  for  bronchoscopy  and 
esophago.seopy  in  small  children.  With  suspension-laryngoscopy  one 
engages  the  larynx  and  then  inserts  the  bronchoscopic  or  esophagoscopic 
tube  into  the  deiiths.  Narcosis  can  be  maintained  without  special  dan- 
ger.    ScilTert  has  shown  that  artificial  respiration  may  be  accomplished 


148 


SUSPENSION  LAKVNGOSCOPY. 


with  the  horizontal  suspension-hook.  One  must  never  neglect  to  co- 
cainize the  larynx  before  inserting  the  instruments  in  order  to  eliminate 
the  vagus-reflexes  emanating  from  the  laryngeal  mucous  membrane. 
With  the  introduction  of  a  cold  instrument  into  the  uncocainized  larynx 
temporary  discontinuance  of  respiration  may  very  readily  occur. 

THKR.'VPECTIC  .\PPLICATIOX   OF  Sl'SPENSION-LARVNGOSCOPV    IN   CHILDHOOD. 

a.     Foreign  Bodies. 

Davis  removed  a  safety-])in  from  the  pliaryn.x  of  an  eleven-months- 
old  child  under  suspension-laryngoscopy.  My  pupil,  ^^'eingaertner,  re- 
centlv  succeeded  in  extracting  a  piece  of  bone  which  was  lodged  partlv  in 


Fig.  125. 


the  phar\nx  and  partly  in  the  entrance  to  the  lar\nx  of  a  child  one  and 
one-half  years  old.  Seiffert  reports  the  removal  of  a  flat  bone  from  the 
sub-glottic  space  in  a  child  of  five  years.  Iglauer  removed  a  piece  of 
safety-pin  which  had  been  lodged  in  the  larynx  of  a  child  for  five  months. 
All  observers  state  that  the  location  and  extraction  of  foreign  bodies 
offer  no  special  difficulties.  The  condition  is  probably  the  same  with 
deep-seated  foreign  bodies  whether  lodged  in  the  esophagus  or  in  the 
larynx  or  bronchus.  A  tube  is  projected  into  these  organs — a  very  simple 
procedure  during  suspension-laryngoscopy.  By  means  of  suspension- 
laryngoscopy  I  succeeded  in  locating  in  and  e.xtracting  from  the  right 
bronchus  a  metallic  capsule.  In  the  same  manner  I  removed  a  nail 
which  had  been  lodged  for  a  year  in  the  left  bronchus  of  a  two-year-old 
child.  Both  cases  impressed  upon  mc  that  this  sort  of  bronchoscopy  is 
easier  and  better. 


SUSPENSION  I.AKYXC.OSCOPY. 


149 


l.AKVNCKAl,    I'AI'IIJ.OMATA    IN    CIIII.DRKN. 

In  my  clinic  we  were  able  to  gather  extensive  data  bearing  on  this 
affection  and  its  treatment.  Albrecht  has  frequently  and  minutely  re- 
ported on  it.  The  new  method  not  only  permits  a  certain  diagnosis  but 
also  a  radical  removal.  Even  if  the  larynx  is  entirely  filled  with  papil- 
lomata,  one  can  remove  everything  at  one  sitting,  if  the  children  are 
already  dyspnoeic,  suspension-laryngoscopy  may  still  be  carried  out. 
Obviously  the  tracheotomy  instruments  must  be  in  readiness.  If  one 
has  succeeded  in  api)lying  the  suspension-hook  one  need  no  longer  fear 


m= 


Fig.  126. 


Fi^.  127. 

asphyxiation,  for  one  caii  w  ithout  furtlu-r  ado  insert  a  bronclioscopic  tulie 
through  the  larynx  and  wait  until  respiration  is  again  in  progress.  The 
larynx  is  always  readily  accessible  in  suspension.  Obviously  one  must 
use  narcosis.  There  is  no  conlra-indication  to  repeat  such  sittings.  As 
the  i>apillomata  readily  recur,  many  cases  re(|uire  numerous  sittings, 
sometimes  even  a  long  series  of  such.  Sometimes  one  succeeds  by  means 
of  internal  remedies,  such  as  i(>(lide  of  potassium  or  arsenic,  to  prevent 
recurrences.  Penciling  with  l«»  ])er  cent  salicyl-alcohol  has  also  been 
recommended.     'i"he  mesolhoriuni-treatment  as  a  remedy  against  recur- 


150 


SUSPENSION  LARYNGOSCOPY. 


-_-:#?» 


Fie.  128. 


SL'SPENSIO.V    LARYNGOSCOPY.  151 

rences  appears  to  me  to  be  one  of  the  most  promising.  However,  we 
have  not  yet  gathered  any  particular  experience.  Albrecht  has  succeed- 
ed in  removing  papillomata  in  a  large  number  of  children.  Others,  too, 
have  reported  favorably  upon  the  application  of  suspension-laryngoscopy 
to  the  removal  of  papillomata.  as  Wolff,  Kleestadt.  Mann  and  Katzen- 
stein.  Seiffert  mentions  a  case  in  which  tracheotomy  was  indicated  but 
in  which  it  was  possible,  by  removal  of  the  papillomata,  to  avoid  that 
operation.  Kahler  has  removed  numerous  papillomata  from  the  hypo- 
])liarynx  and  eso])hageal  entrance  of  a  three  and  one-half  year  old  chikl. 

NODULKS  Ol-"  VOC.\L  CORDS. 

Xoduk's  upon  llie  vocal  cords  of  children  arc  not  at  all  rare.  They 
are  usually  accompanied  by  a  slight  catarrh  and  cause  a  permanent 
hoarseness.  ( )ften  we  have  to  deal  with  children  who  suft'er  from  im- 
perfect nasal  respiration  in  consequence  of  hv|)ertrophy  of  the  pharyn- 
geal tonsils,  turbinal  swelling  and  septal  deflections.  Frequently  one  can 
prove  that  the  children  have  cried  very  much  for  a  long  period. 

Most  young  patients  do  not  permit  intcrveiUions  in  their  larynx. 
One  can  therefore  only  work  by  the  direct  method  under  narcosis.  Sus- 
pension-laryngoscopy is  particularly  ada])ted  for  this,  as  has  been  em- 
phasized by  Seift'ert  and  b\  Katzenstein.  M\-  best  results  have  likewise 
been  with  this  method.  The  nodules  are  removed  with  a  small  forceps 
or  a  small  guillotine. 

In  diphtheria,  in  s_\pbilis  ami  in  tulierculosis  in  children,  suspension- 
laryngoscojn-  is  chiefly  used  merely  for  diagnostic  purposes,  although  we 
have  already  begun  to  make  curettements  and  excisions  in  rare  cases  of 
laryngeal  tuberculosis.  Difficult  decanulement  should  more  frequently 
prompt  us  to  undertake  susjjension-laryngoscopy.  As  has  been  proved 
one  can  thus  readily  obtain  a  clear  view  of  the  larynx.  One  can  also  as- 
certain the  conditions  in  the  subglottic  region  and  granulation- formation 
over  the  canula.  It  may  become  necessary  to  insert  a  lube  thrciui^h  the 
rima  glottidis  in  order  lo  approach  these  granulations.  I'.\en  Seilfert 
rejjorts  a  case  with  subglottic  granulations. 

TNTKKVICNTIONS  IN    Tl  I  !■:  OKo-l'l  I  AUV  N  \    A.M)   IN   T  1 1  I'.    i:S(il' M  ACTS. 

.\lbrecht.  h'reudenthal  .-nid  1  |H-rforme(l  tonsdlectoniies  in  small  chil- 
dren imder  narcosis  by  use  of  a  broad  tongue-spatula  with  the  susjien- 
sion-hook.  When  one  works  on  the  suspended  head  one  sees  the  tonsils 
reversed.  Their  up|)er  pole  appears  to  be  below.  (")ne  must  therefore 
accordingly  change  the  technique.  Tt  is  very  convenient  that  luniorrliage 
causes  no  great  trouble.  The  blood  flows  into  the  naso-phar\n.\  and  cm 
be  drawn  by  suction  from  there  through  the  nose. 


153 


SUSPENSION  LARYNGOSCOPY. 


SUSPENSION-l.ARYNGOSCOPY  IN  ADULTS. 

In  the  adult  suspension-laryngoscopy  is  chiefly  used  in  tuberculosis 
of  the  larynx,  especially  when  one  contemplates  curetting  a  diseased  por- 
tion. One  will  decide  in  favor  of  this  method,  especially  in  the  cases  of 
advanced  laryngeal  tuberculosis,  for  it  puts  us  in  position  to  undertake 
extensive  work  at  one  sitting,  to  curette,  to  nip  off  or  even  to  make  one 
or  two  deep  galvanic  punctures.  It  is  very  important  that  phthisic  pa- 
tients who  are  to  enter  a  sanitarium  be  relieved  of  the  most  pronounced 
changes  in  the  larynx. 

Suspension-laryngoscopy  can  be  carried  out  under  local  anaesthesia 
in  such  cases  following  administration  of  one  morphine  injection.  In  or- 
der to  reduce  the  great  reflex  irritability  of  the  tuberculous  larynx,  how- 


Fig.  129. 
ever,  it  is  advisable  in  just  such  cases  to  make  use  of  the  skopolamin- 
morphine  "twilight  sleep."       We  have  never  seen  serious  disadvantages 
from  it.    On  the  other  hand,  narcosis  does  not  seem  to  be  especially  w-ell 
borne  by  some  tuberculars. 

When  a  tuberculous  larynx  has  been  engaged  with  the  suspension- 
hook,  it  is  advisable  to  attach  a  glass  shield  to  the  gallows  before  be- 
ginning the  currettement  so  that  tuberculous  material  may  not  be  coughed 
into  one's  face  (compare  Fig.  1?4). 

For  curettement  I  have  had  a  reversible  curette  constructed  (Fig. 
125).  The  nipping  off  of  infiltrations  and  granulations  is  done  with  the 
ordinary  double-curette  for  direct  operations  (compare  Fig.  12G  and 
127).    In  cases  of  hemorrhage,  clamps  may  he  applied  (  Fig.  128). 

The  galvano-caustic  deep  puncture  may  be  executed  with  great  se- 
curity.    An  ordinary  pointed  cautery  electrode  which  must  be  at  least 


SUSPENSION  LARYNGOSCOPY. 


153 


20  cm.  in  lenglli  is  used   for  this  purixisc.     'i'heii  tliu  larynx  is  painted 
with  hydrogen  peroxide  and  insulHated  w  ith  \  ioform  or  anesthesin. 

The  subset|iient  manii)iilation  in  the  larynx  must  be  under  guidance 
of  the   laryngeal    mirror,      .\ftcr   maior   incursions   oedema   mav   readily 


Fig.  130. 

occur.  For  successfully  combating  such  incidents  we  now  have  an  ex- 
cellent remedy  in  the  hot-air-chest  of  .Albrccht  which  can  be  used  again 
the  same  day  if  necessary.  (Fig.  12!)).  Temperatures  up  to  110  degrees 
Celcius  can  be  aiiplied.  'i'be  skin  of  the  neck  bears  this  dry  heat  very 
well  if  the  chest  is  well  lined  with  asbestos-fibre.  A  strongly  active  hy- 
peraemia  results  and  the  oeclemas  are  re-absorbed.  The  [iroccdure  has 
an  anodyne  effect.  Of  course  the  jiatient  always  complains  of  pain  dur- 
ing the  first  few  days.  This  is  caused  not  alone  by  the  wounds  in  the 
larynx,  but  also  by  the  [jressure-elTcct  of  the  lingual  and  lar\ngeal  spat- 
ulas.    One  also  frequently  observes  temperature-elevations  of  minor  or 


154.  SUSPENSION   LARYNGOSCOPY. 

greater  degree,  which  \ery  readily  occur  from  \arious  causes  in  tuber- 
cular patients.  They  soon  subside.  I  prefer  in  the  after-treatment,  to 
give  iodine  internally  and  peroxide  of  hydrogen  locally.  It  is  also  ad- 
vantageous to  continue  treating  the  cleansed  wounds  of  the  larynx  with 
lactic  acid. 

Obviously  the  result  of  such  operative  treatment  depends  upon  the 
state  of  the  lungs  and  the  general  condition.  Patients  who  can  imme- 
diately receive  sanatorium  treatment  have  good  chances  of  cure  if  the 
larynx  be  primarily  aiTected. 

By  adopting  radical  measures  in  the  larynx,  tracheotomy  has  often 
been  obviated  (  Holscher.  Seiffert,  Freudenthal  >.  Exposure  of  the  tuber- 
culous larynx  to  Roentgen-rays  through  the  lumen  has  also  been  success- 
fully accomplished  in  suspension-laryngoscop}-  by  Brieger  and  his  pupil. 
SeifYert. 

In  difficult  cases  of  pol\ps  of  the  \ocal  cords,  especially  when  the 
polyps  were  located  far  anteriorly.  Hoelscher  and  Steiner  used  suspen- 
sion-laryngoscopy  with  the  best  results.  E.  Allayer  has  successfully  re- 
moved a  carcinoma  of  the  epiglottis  under  suspension-lar\-ngoscopy.  It 
has  further  been  applied  in  scleroma,  and  even  in  hysterical  aphonia. 

A  new  field  has  arisen  for  it  in  mesothorium  treatment  of  laryngeal- 
carcinoma,  about  which  I  have  recently  made  a  report.  I'.y  means  of 
suspension-laryngoscopy  not  only  can  the  small  mesothoriuni-capsule  be 
applied  lo  the  diseased  spot  introduced  into  the  carcinoma  under  skopo- 
iamine-morphine  narcosis,  but  especially  the  sitting  ma}-  lie  extended 
sufficiently  long.  The  patient  may  be  left  in  suspension  one  hour,  or 
even  one  and  one-half  hours  (probably  even  longer)  without  compunc- 
tion  (Fig.  1 :!()). 

The  mesothorium-capsule  is  provided  with  an  aluminum-filter  at- 
tached to  a  cord  and  inserted  into  the  lar\-nx  with  an  ordinary  claw- 
force])s.  Tlie  instrument  is  secured  with  cords  or  clamps.  Thus  it  will 
remain  quietly  in  position  the  entire  time.  During  the  first  days  there  is 
generally  a  light  infiammatory  reaction,  but  the  improvement  in  the  carci- 
nomatous condition  is  soon  apparent. 

Suspension-laryngoscopy  is  peculiarh-  adapted  for  examining  and 
treating  operatively  changes  in  the  lower  pharynx.  True,  one  ordinarily 
requires  the  additional  help  of  a  dilator  to  separate  the  larynx  from  the 
spinal-column.  Seiffert  has  reported  more  in  detail  regarding  this  as- 
pect. I  am  not  able,  at  this  time,  to  state  how  extensively  esophagoscopy 
may  be  used  in  the  adult  in  suspension.  Apparently  this  procedure  is  of 
great  advantage  in  the  removal  of  voluminous  foreign  bodies  which  are 
wedged  within  range  of  the  esophageal  opening  or  immediately  below  it 
(Brieger).  Seiffert  reports  the  removal  of  a  coin  from  the  hypopharynx 
in  two  small  children.  He  also  was  successful  in  the  remoxal  of  a 
lijioma  from  the  hypoph.-uwnx  during  suspension. 


CHAPTER     IX. 

Introduction  of  the  Bronchoscope. 

The  descrii)lion  of  the  intruducticjn  of  the  bronchoscope  given  in 
some  of  the  text-books  woultl  lead  one  to  suppose  that  the  procedure  is 
difficult  and  some  books  e\en  go  .so  far  as  to  say  that,  if  after  fifteen 
minutes'  trial  the  operator  fails  to  introduce  the  instrument,  a  tracheot- 
omy should  be  done  for  introduction.  This  state  of  affairs  is  almost  in- 
conceivable. Xo  one  should  do  lironchoscopy  until  he  is  able  laryngos- 
copically  to  exjjose  the  glottis  with  the  left  hand  in  not  more  than  one 
minute,  and  having  learned  this,  it  ought  not  to  reijuire  over  one  min- 
ute more  to  introduce  the  bronclioscope  into  the  trachea.  The  usual 
time  should  be  from  fifteen  to  thirtv  seccMids,  depending  on  how  long 
the  patient  holds  his  breath  (if  not  anesthetized),  before  taking  a  deep 
inspiration.  This  length  of  time  applies  to  infants  as  well  as  adults. 
Whatever  may  be  said  of  the  difiiculties  of  bronchoscopy  in  infants,  be- 
cause of  the  smallness  of  the  tube,  it  does  not  apply  to  the  introduc- 
tion of  tlie  bronchoscope  by  ihe  auilun's  method,  because  of  the  large 
diameter  of  the  author's  laryngoscope  for  infants  (12  mm.).  This  size 
is  [jossible  because  the  laryngoscope  by  the  author's  method  does  not  go 
through  the  larynx — simply  exposes  its  upper  orifice  to  view.  Once  tiie 
larynx  is  properly  exposed  there  should  be  no  diriicuity  in  introducing 
even  the  4  mm.  tube.  This  is  not  mentioned  jjoast fully  nor  as  urging 
hasty  procedure:  but  rather  to  urge  the  necessity  of  abundant  practice 
in  left-handed  larxngoscopic  exposure  of  the  glottis. 

INTRODUCTIO.N     Ol'     Till-;     nUONCHOSCOPK,     P.STIKNT     SITTING. 

I'or  the  nitroduclion  of  the  bronchoscope  in  the  sitting  position,  the 
patient  is  usually  locally  anesthetized,  the  details  for  which  are  given 
in  a  sc])arate  cliai)ter.  This  position  is  advisable  only  in  adults  and  only 
for  diagnosis.     The  position  of  operator,  patient  and  assistants  is  pre- 


156 


INTRODUCTION  OF  TEIK  BRONCHOSCOPIC. 


Fig.  i,;i. — Schema  illustrating  oral  bronchoscopy.  The  portion  of  the  table 
here  shown  under  the  head  is,  in  actual  work,  dropped  all  the  way  down  perpen- 
dicularly. It  appears  in  these  drawings  as  a  dotted  line  to  emphasize  the  fact  that 
the  head  must  be  above  the  level  of  the  table  during  introduction  of  the  broncho- 
scope into  the  trachea.  A,  exposure  of  larynx.  B,  bronchoscope  introduced.  C, 
slide  removed.  D,  laryngoscope  removed  leaving  bronchoscope  alone  in  position. 
The  handle  of  the  laryngoscope  in  C  and  D  should  be  shown  as  rotated  down  to 
the  left  as  shown  in  Fig.  131a. 


INTRODUCTION  OK  THE  BRONCHOSCOPE.  157 

cisely  the  same  as  for  direct  laryngoscopy,  as  shown  in  Fig.  70  and  de- 
scribed in  the  adjacent  text.  After  the  larynx  is  exposed  as  there  de- 
scribed the  introduction  of  the  bronchoscope  is  precisely  the  same  as  in 
the  recumbent  position,  so  that  the  one  description  of  the  procedure 
will  answer  for  both.  The  only  difference  is  that  the  laryngeal  image  is 
sagitally  reversed. 

INTRODUCTION    OF   THE   BRONCHOSCOPE.      RECUMBENT    P,\TlENT. 

The  patient  being  in  the  Boyce  ])Osition,  as  illustrated  in  Figs.  72 
and  73.  the  glottis  is  exposed  with  the  larj-ngoscope  as  shown  in  Fig. 


z'\ 


/ 

I 

I 


X 


Fig.  i.5la. — Before  removing  tlie  slide  the  handle  of  llie  laryngoscope  should 
be  moved  to  the  left  from  position  Z  to  position  X,  rotating  the  laryngoscope  90 
degrees  on  its  tubular  axis  (Y).  This  movement  clears  the  slide  of  all  contact 
Eo  that  it  comes  of?  quickly.  Used  thus,  the  regular  laryngoscope  (Fig.  14)  is 
preferable  to  the  side-slide  or  any  form  of  open  laryngoscope  for  the  introduction 
of  bronchoscopes. 

02.  of  which  A,  Fig.  KM,  is  a  reproduction.  The  same  thing  is  shown 
in  Fig.  I.'i3.  'i'he  ojjcrator  watches  the  larynx  which  is  brilliantly  illu- 
minated by  the  light  of  the  laryngoscope,  while  the  first  assistant  hands 
him  the  bronchoscope  lighted  with  its  own  lamp.  ( Xo  warming  or  oil- 
ing is  necessary).  The  inslrunicnt  is  jiassed  to  the  operator,  properly 
pointed  toward  the  proximal  end  of  the  speculum  so  that  llie  operator 
has  but  to  reach  up  his  right  hand,  grasp  tlie  bronchoscope  and  start  it  in, 
catching  the  handle  of  the  bronchoscope  that  is  passed  to  him  by  the 
assistant.  The  bronchoscope  is  inserted  with  the  handle  horizontally  to 
the  right  (Fig.  l-M.'!).  The  eye  is  now  transferred  from  the  laryngo- 
scope to  the  bronchoscope,  and  the  bronchoscope  is  advanced  until  the 


]58 


INTRODUCTION  OF  THE  BRONCHOSCOPE. 


Fig.   132. — Exposure  of  the  larynx  of  the  recumlient  patient.     The  operator  is 
lifting  stronsly  in  the  direction  of  the  dart. 


Vti':  133. — Insertion  of  the  bronchoscope.  Note  direction  of  the  trachea  as  in- 
dicated by  the  bronchoscope.  Note  that  the  patient's  head  is  held  above  the  level 
of  tlie  table.  The  assistant's  left  hand  should  be  at  the  patient's  month  holding  the 
bite-block.  This  is  removed  and  the  assistant  is  on  the  wrong  side  of  tlie  table  in 
the  ilhistration  in  order  not  to  hide  the  position  of  the  nperatnr's  liands.  Note  the 
handle  of  the  bronchoscope  is  to  the  right. 


INTRODUCTION   01'   THIC  BKONCIIOSCOPK. 


35D 


inner  end  approaches  (|uitc  closely  to  llie  jjlottis.  If  no  anesthesia  is 
used,  it  is  to  be  iireferred  thai  the  distal  end  of  the  hronchoscope  does 
not  touch  tlie  larynx  lest  an  excess  of  spasm  be  excited,  which  would  de- 
lay the  insertion.  The  handle  of  the  bronchoscope  is  now  moved  slightly 
to  the  right  so  as  to  throw  the  lip  of  the  slanted  end  over  into  the  median 
line   of   the  glottic   chink,   as   will   be   understood    from    Fig.    i:vl.      This 


Fic.  134. — Schema  illustrating  tlic  introduction  of  the  lironchoscope  through  the 
glottis,  recumbent  patient.  The  handle,  H,  is  always  horizontally  to  the  right.  When 
the  glottis  is  first  seen  through  the  tube  it  should  I)c  centrally  located  as  at  K.  At 
the  next  inspiration  the  end,  B,  is  moved  horizontally  to  the  left  as  shown  by  the 
dart,  M,  until  the  glottis  shows  at  the  right  edge  of  the  field,  C.  This  means  that 
the  point  of  the  lip,  B,  is  at  the  mcilian  line  and  it  is  then  quickly  (not  violently) 
pushed  through  into  the  trachea.  At  this  same  moment  or  the  instant  before,  the 
hyoid  Ixine  is  given  a  (juick  additional  lift  with  the  tip  of  tlie  laryngoscope  as  shown 
by  the  dart  (Fig.  132)  and  at  A  in  Fig.  13T.  In  the  sitting  patient  everything  is 
the  same  except  that  the  larvnceal  image  is  reversed  sa'.^illally  .lud  laterally. 


sliding  over  should  preferably  be  done  at  the  moment  that  an  inspira- 
tion starts,  so  that  the  bronchoscope  can  be,  at  the  same  time,  inserted 
through  the  glottis.  Herein  lies  a  great  advantage  in  the  slanted  end, 
because  it  is  very  much  easier  to  insinuate  the  li])  of  the  slanteil  end 
through  the  chink,  than  to  insert  the  end  of  a  tube  which  is  scpiarelv 
cut  off.     Care  should  be  taken  not  to  allow  the  lube  to  become  hooked 


160  INTRODUCTIOX  OF  THE  BRONCHOSCOPE. 

over  the  arytenoid,  though  there  is  less  Hkehhood  of  this  in  bronchos- 
copy than  there  is  in  esophagoscopy.  Ko  great  force  should  be  used, 
because  if  the  bronchoscope  does  not  go  through  readily  either  the  tube 
is  too  large  in  size  or  it  is  not  correctly  placed.  On  the  other  hand,  the 
tube  does  not  normally  go  through  without  slight  resistance,  and  the 
laryngologist  or  rhinologist  who  has  been  trained  to  manipulative  pro- 
cedures, will  very  readily  determine  by  his  sense  of  touch  the  degree  of 
pressure  necessary,  and  will  not  use  a  degree  that  will  inflict  trauma. 
If  the  attempt  is  made  to  insert  a  5  mm.  tube  through  the  glottis  of  an 
infant  under  one  year,  there  may  be  considerable  resistance,  and  if  so, 
subglottic  edma  is  quite  likely  to  follow  forcible  introduction.  On  the 
other  hand,  a  -i  mm.  tube  should  go  through  with  practically  no  resist- 
ance, if  properly  placed.  Once  through  the  glottis  (B,  Fig.  lol)  the 
direct  laryngoscope  should  be  removed  as  shown  schematically  at  C,  Fig. 
]31.  The  laryngoscope  is  turned  sidewise  just  before  removal  (Fig.  131a) 
so  that  the  slide  will  not  impinge  on  the  upper  teeth.  Care  must  be  taken 
that  the  bronchoscope  is  not  allowed  to  be  cotighed  out  during  the  re- 
moval of  the  speculum.  The  bronchoscope  is  most  easily  held  in  place 
by  the  thumb  of  the  left  hand  of  the  operator,  while  the  thumb  and  finger 
of  the  right  hand  are  used  to  remove  the  slide.  At  the  moment  of  in- 
sertion of  the  bronchoscope  through  the  glottis,  an  especially  strong 
upward  lift  with  the  beak  of  the  spatula  is  usually  necessan,'  in  order  to 
permit  the  brcinchoscope  to  be  given  also  a  forward  t'.lt  into  the  glottis 
This  prevents  the  bronchoscope  reaching  the  posterior  slant  of  the  party 
vi'all  which  would  drift  it  off  into  the  esophagus.  The  distance  of  in- 
sertion of  the  bronchoscope  into  the  trachea  before  removal  of  the 
speculum  is  to  be  determined  by  experience.  Usually  if  it  has  passed 
two  or  three  tracheal  rings  it  will  be  found  sufficiently  deep.  In  case 
a  foreign  body  is  expected  to  be  located  in  the  trachea,  it  is  better  not 
to  exceed  this,  lest  the  foreign  body  be  dislodged  and  move  downward. 
For  the  same  reason,  the  trachea  should  always  be  carefully  in- 
spected with  the  direct  laryngoscope  before  attempting  to  insert  the 
bronchoscope,  unless  there  is  very  serious  dyspnea.  It  is  very  neces- 
sary to  be  certain  that  the  axis  of  the  bronchoscope  corresponds  with 
the  axis  of  the  trachea,  before,  as  well  as  after,  the  bronchoscope  is  in- 
serted, otherwise  the  distal  end  of  the  bronchoscojje  will  impinge  on  the 
tracheal  mucosa,  inflicting  trauma  which  is  one  of  the  factors  in  the 
production  of  subglottic  edema.  In  this  connection  it  must  be  repeated 
here  that  the  direction  of  the  trachea  is  not  perpendicular  to  the  long 
axis  of  the  body,  but  that  it  follows  the  thoracic  spine  backward  as  well 
as  downward,  as  seen  in  the  schema.  Fig.  (il.  To  get  this  direction,  in  the 
recumbent  patient,  the  patient's  head  must  be  elevated,  and  at  the  same 


INTRODUCTION  OF  THE  BRONCHOSCOPE.  161 

time  It  must  be  closelv  observed  that  the  patient's  head  is  neither  ro- 
tated nor  bent  to  one  side  or  the  other.  The  accurate  placing  of  the 
head  will  be  watched  carefully  by  a  trained  assistant,  but  the  operator 
should  also,  without  direct  looking,  be  able  to  determine,  in  a  general 
way,  the  position  of  the  patient's  head  and  neck.  The  better  the  second 
assistant  and  the  longer  he  and  the  operator  have  worked  together,  the 
better  the  work  they  will  do  and  the  more  the  operator  will  come,  un- 
consciously, to  depend  upon  the  assistant  to  keep  the  head  in  position. 

Difficulties  in  the  introduction  of  the  bronchoscope.  The  foregoing 
is  a  description  of  how  to  introduce  the  bronchoscope,  and  if  closely 
followed,  no  one  after  a  little  practice  should  have  any  difficulty  in  the 
introduction  in  a  patient  fully  relaxed  by  a  general  anesthetic.  If  any 
serious  ditliculties  are  met  with,  some  of  the  details  have  been  over- 
looked, such  as  full  extension  of  the  head,  elevation  of  the  head,  lift- 
ing strongly  with  the  tip  only  of  the  laryngoscope  at  the  moment  of  in- 
sertion of  the  bronchoscope  in  the  glottis.  ^ 

The  beginner  will  occasionallv  enter  the  esophagus  instead  of  en- 
tering the  trachea.  This  is  a  verv  dangerous  accident,  in  dyspneic  cases, 
not  only  by  default  in  not  entermg  the  trachea,  but  directly  by  compres- 
sion of  the  trachea  through  the  bulk  of  the  esophagoscope  in  the  eso- 
phagus. Under  normal  conditions,  if  properly  passed,  an  esophagoscope 
docs  not  compress  the  trachea  to  any  appreciable  extent,  as  the  author 
has  previously  demonstrated  by  inserting,  at  the  same  time,  the  broncho- 
scope in  the  trachea  and  an  esophagoscope  in  the  esophagus ;  but  in  dysp- 
neic cases,  it  takes  but  very  little  displacement  of  the  esophagus  to  in- 
crease the  dyspnea  to  the  point  where  respiration  will  be  arrested.  For 
another  reason  it  is  essential  to  avoid  putting  the  bronchoscope  into  the 
esophagus  accidentally  first  before  introducing  it  into  the  larynx,  because, 
if  properly  done,  the  bronchoscope  can  be  introduced  through  the  laryn- 
goscope without  coming  in  contact  with  the  secretions  contaminated 
from  the  mouth.  The  trachea  is  not  a  septic  canal,  while  the  esophagus 
swarms  with  bacteria.  Getting  into  the  esophagus  is  simply  due  to  the 
neglect  of  some  of  the  details  just  mentioned,  especially  insufficient  glot- 
tic exposure  and  defective  position  with  failure  to  lift  strongly  with 
the  spatular  tip  at  the  moment  of  passing  the  glottis.  It  is  not  always  as 
easy  as  might  be  supposed  to  detect  the  entrance  of  the  bronchoscope 
into  the  esophagus.  There  is  a  very  distinct  respiratory  movement  to 
the  esophagus,  but  it  is  in  no  way  equal  to  the  ex[)iratory  tracheal  blast 
and  the  ])ink,  smooth,  collapsing  walls  of  the  esophagus  are  in  marked 
contrast  to  the  normal  trachea  in  which  the  rings  of  slightly  deei)er  color 
contrast  with  those  of  the  almost  white  nuicosa  covering  the  cartilagi- 
nous rings.    In  a  state  of  disease,  lK)wever,  the  tracbeal  nuicosa  may  be  so 


162  INTRODUCTION  OF  THE  BRONCHOSCOPE. 

swollen  and  edematous  that  tlie  rings  are  obliterated,  and  in  children 
there  is  more  or  less  collapse  of  the  tracheal  wall  during  expiration,  es- 
pecially the  forced  expiration  of  cough,  as  illustrated  in  the  section  on 
the  normal  bronchoscopic  image.  In  the  esophagus  there  will  usually  be  a 
free  flow  of  secretion  in  the  distal  end  of  the  tube,  which  obscures  the 
field :  and  the  secretion  usually  flows  also  through  the  lateral  opening 
of  the  bronchoscope.  There  mav  be  secretions  in  the  trachea,  but  it  is 
seldom  the  free  flow  that  is  seen  in  the  esophagus.  The  main  point  of 
distinction,  however,  is  the  tracheal  blast,  if  the  patient  be  breathing  or 
coughing.  In  cases  of  respiratory  arrest,  there  is  usually  no  spasm  what- 
ever, and  the  freely  open  trachea  is  readily  recognized.  In  such  cases, 
however,  the  error  of  inserting  the  bronchoscope  into  the  esophagus  may 
prove  fatal  to  the  patient ;  not  only  by  default  in  not  getting  prompt 
aeration  and  oxygen  insufflation,  but  also  by  the  bulk  of  the  bronchoscope 
in  the  esophagus  compressing  the  lumen  of  the  trachea.  In  working 
without  an  anesthetic,  general  or  local,  this  danger  is  practically  nil. 

If  the  patient  is  profoundly  anesthetized,  there  is  no  halting  of  the 
rhythmic  respiratory  excursion,  and  the  bronchoscope  is  verv  readily  in- 
troduced through  the  glottis  without  the  slightest  resistance.  If,  how- 
ever, the  patient  is  insufficientU  anesthetized,  either  locally  or  general- 
ly, and  especially  if  unanesthetized  as  in  children,  the  glottis  may  re- 
main closed  for  a  considerable  length  of  time.  In  tracheotomized  cases 
the  glottis  may  remain  closed  indefinitely,  and  the  bronchoscope  should 
be  insinuated  through  without  waiting;  but  in  untracheotomized  cases, 
if  not  dyspneic,  it  is  better  to  wait  for  the  relaxation  of  the  spasm  and 
opening  of  the  glottis  that  comes  with  the  first  deep  inspiration.  In  old- 
er children,  or  in  locally  anesthetized  adults,  the  command  to  take  a  deep 
breath  will  usually  be  obeyed,  especially  if  the  necessity  for  deep  breath- 
ing has  been  repeatedly  urged  from  the  beginning.  It  is  not  advisable 
with  an  incompletely  anesthetized  patient,  especially  if  chloroform  has 
been  used,  and  still  more  especially  if  both  chloroform  and  morphine 
have  been  used,  to  wait  too  long  for  the  glottis  to  open,  as  the  respira- 
tion may  cease.  In  these  cases  it  is  better  to  push  the  bronchoscope 
through.  In  all  dyspneic  cases  the  opening  of  the  glottis  should  not  be 
awaited  for  more  than  a  few  seconds.  The  bronchoscope  should  be 
pushed  through,  not  violentlv  or  roughly,  but  with  the  firmness  and  pre- 
cision gained  from  the  knowledge  that  the  tube  is  the  right  size  for  the 
patient,  that  it  is  properly  placed,  and  that  the  patient  is  in  the  correct 
position. 

\^ery  often  I  have  found  that  the  difticulties  which  beginners  have 
encountered  in  inserting  the  bronchoscope  have  been  due  to  the  use  of  a 
gag.     Very  wide  gagging  will  render  the  insertion  of  a  bronchoscope,  or 


INTROUL'CTIOX  OF  THlv   URONCHOSCOPE.  163 

even  the  exi)osiire  of  the  larynx,  difficult  if  not  impossible.  There  is 
no  need  for  a  gag  for  any  other  purpose  than  simply  to  prevent  the  pa- 
tient biting  the  tube,  and  for  this  the  bite  block,  shown  in  Fig.  39  is 
ideal,  because  it  is  readily  held  in  place  at  all  times  by  the  first  finger 
of  tl;e  second  assistant,  and  because  it  does  not  slip,  regardless  of  how- 
imperfect  the  patient's  teeth  may  be. 

E.vploration   of  the   trachea  and   bronchi.     After   the  bronchoscopic 
tubc-niouth    has   entered   the   trachea  there   will   usually  be   encountered 
more  or  less  secretion,  according  to  the  nature  of  the  case,  the  anesthetic 
and  drugs  used.  etc.    This  secretion  must  be  removed  at  once,  before  any 
deeper  insertion  of  the  bronchoscope  is  made  in  order  that  we  have  the 
safety  of  sight.      In  foreign-body  cases  this  is  especially  necessary   lest 
the  intruder  be  pushed  down.     For  the  same  reason,  sponges  must  be  in- 
serted only  just  beyond  the  tube-mouth,  which  distance  can  be  determined 
by  the  sensation  imparted  to  the  finger  and  thumb  when  a  properly  fit- 
ting sponge  emerges  from  the  distal  tube-mouth.     Having  removed  the 
secretions    by   the  author's   "sponge    pumping"   process    in   the   manner 
illustrated  in   Fig.  '2'>,  and  explained  under  "Aspirators,"  the   broncho- 
scope is  carefully  advanced.     If  the  bronchoscope  or  the  trachea  become 
filled  with  secretion  coughed  from  the  lower  air  passages,  advance  of  the 
tube  must  be  stopped  as  often  as  necessary  until  the  secretion   is   re- 
moved, lest  a  foreign  body  be  overridden  or  a  diseased  area  be  over- 
looked.    While  it  is  true  that  the  tracheo-bronchial  tree  is  very  elastic, 
and  consequently  will  adapt  itself  in  a  wonderful  degree  to  the   faults' 
direction  of  the  bronchoscope,  yet  it  is  essential,  wherever  possible,  to 
follow  the  lumen  as  it  opens  up  ahead  of   the  tube  mouth.       As    has 
just   been   said,   a  well-trained   assistant    will  at   the   introduction   of  the 
bronchoscope   have   the   head   so   held   that    the   trachea    will   be   in    line 
ahead  of  the  bronchoscope.     In  the  further  exploration  of  the  tracheo- 
bronchial   tree,   the   second   assistant   should    busv   himself    with    making 
sure  that  the  head  is  so  held  that  the  lani'ux  shall  in  the  least  possible 
degree    become   the    fulcrum    upon    which    the    bronchoscope    rests.      In 
other  words,  when  the  position,  into  which  the  operator  in  pursuit  of  the 
lumen  swings  the  bronchoscope,  causes  the  bronchoscoijc  to  bear  upon 
the  larynx  as  a  lever  upon  its   fulcrum,   the  laryngeal   fulcrum  should 
be  eased  off  for  two  very  important  reasons : 

1.  An  unyielding  laryngeal  fulcrum  limits  exploration  because  of  its 
distance  from  the  upjier  thoracic  aperture. 

2.  If  the  larynx   is  not  eased  away   when    fulcral   pressure  comes 
ui)on  it.  this  pressure  will  cause  subglottic  edema. 

Therefore  a   fundamental   rule  which  must  be   rigidly  observed   by 
the  bronchoscopist  and  especially  by  his  second  assistant  is:     The  fid- 


164  INTRODUCTION  OF  THE  BRONCHOSCOPE. 

ciuDi  of  the  bronciwscopic  lever  is  at  the  upper  thoracic  aperture;  never 
at  the  larynx  (Schema.  Fig.  IS.J). 

To  accomplish  this  the  head  and  neck  must  gently  be  made  to  fol- 
low the  direction  of  the  proximal  end  of  the  bronchoscope. 

The  freedom  of  movement  of  head  and  neck,  with  synchronous 
undistorted  status  of  the  thoracic  cage  requires  the  Boyce  position.  In 
no  other  way  can  the  same  results  be  accomplished.  The  nearest  ap- 
proach to  this  position  as  to  movability  of  the  head  and  neck  is  the  lateral 
recumbent  position,  which  is  very  objectionable  because  of  the  varj^ing 
position  of  the  thorax,  the  less  manageable  head,  and  the  inconvenience 
in  the  exploration  of  the  uppermost  lung  or  the  alternative  of  turning  the 


Fig.  135. — Illustrating  the  fallacy  of  supposing  there  is  a  wider  range  of  move- 
ment possible  by  tracheotomic  than  by  oral  bronchoscopy.  If  the  larynx  were 
rigidly  fi.xed  at  L,  the  lateral  range  of  movement  possible  would  be  relatively  slight 
as  compared  to  tracheotomic  bronchoscopy.  But  by  bending  the  neck  sharply  to 
one  side  we  bring  the  larynx  from  H  to  E,  permitting  the  use  of  the  entire  upper 
thoracic  aperture.  This  illustration  also  shows  how  the  second  assistant  by  easing 
away  the  lar3-nx  from  H  to  E  makes  the  upper  thoracic  aperture  the  fulcrum  of 
the  bronchoscopic  lever  instead  of  the  laryn.x,  thus  preventing  undue  pressure  on  the 
larynx  and  consequent  subglottic  edema. 

patient — a  time-wasting  procedure  that  is  intolerable  to  anyone  who  has 
experienced  the  comfort,  satisfaction  and  facility  of  work  in  the  Boyce 
position  of  the  patient  maintained  by  an  assistant  who  has  worked  a  long 
time  with  the  operator. 

To  accomplish  the  making  of  the  upper  thoracic  aperture  (instead 
of  the  larynx)  the  fulcrum  of  the  bronchoscopic  lever,  the  second  assistant 
must  have  a  good  general  sense  of  direction  and  must  have  a  mental  pic- 
ture of  the  position  and  direction  of  the  long  axis  of  the  part  of  the 
tube  in  the  patient  which  he  must  gain  from  the  uninserted  portion  of 
the  tube.  If  the  tube  is  deeply  inserted  he  must  mentally  "'line  up"  the 
position  of  the  bronchoscope  in  the  patient  from  an  imaginary  line  drawn 
from  the  proximal  tube-mouth  to  the  bronchoscopist's  right  eye.     This 


IXTKODL'CTION   Ol"  Till-:   nKONCUOSCOPli. 


165 


line  must  necessarily  be  a  prolongation  of  the  long  axis  of  the  bron- 
choscope. The  axial  line  of  the  tube  and  the  upper  thoracic  aperture 
and  their  relations  to  each  (jUkt  must  be  constantly  in  the  mind  of  the 
second  assistant. 

In  the  descriptions  before  and  hereafter  given  of  various  positions 
of  the  head  and  neck  it  is  to  lie  understood  that  these  in  no  way  inter- 


FiG.  136. — Radiograph  of  bronchoscope  in  the  right  upper  lobe  bronchus  of  a 
woman  of  25  years.  The  bronchoscope  was  inserted  through  the  mouth  and  the 
angle  is  shown  to  be  as  advantageous  as  would  be  possible  through  a  tracheotomic 
wound.  The  position  of  the  patient  is  easy  and  natural  in  this  instance,  the  radio- 
graph being  made  for  verification  of  the  overlay  localization  in  a  suspected  case  of 
interlobar  al)scess.  Had  demonstration  been  the  object,  the  upper  part  of  the  lube 
could  easily  have  been  l)rought  to  the  clavicle.  The  lesser  shadow  passing  down- 
ward is  from  pus  and  shows  the  location  of  the  middle  and  inferior  lobe  (stem) 
bronchi.  This  radiograph  also  shows  that  the  limit  of  lateral  movement  is  fixed 
by  the  upper  thoracic  aperture;  not  by  the  larynx,  hence  tracheotomy  is  of  no  ad- 
vantaf^e  for  bronchoscopy,  so  far  as  angle  is  concerned. 


fere  with  the  endnscopist  following  lln'  lumen  unr  the  second  assistant 
following  the  operator.  "S'et  it  is  necessary  to  know,  in  a  general  wa\', 
the  jwsitions  of  the  patient's  head  and  neck  that  will  be  re(|uire(l  prop- 
erly to  enable  a  correct  presentation  of  the  desired  objective  point. 

With  all  the  foregoing  clearly  in  the  mind  of  operator  and  assistant 
we  are  readv  to  proceed  down  the  trachea,  determining  as  we  go   the 


166  INTROOrCTlON   OF  THE   BRONCHOSCOPE. 

proper  direction  by  endoscopic  watch  of  the  wall  of  the  trachea  as  it 
opens  up  ahead.  The  endoscopist  should  not  see  either  wall  more  than 
the  other,  but  with  a  properly  directed  tube  should  be  looking  directly 
downward  into  the  tracheal  lumen.  If  he  sees  the  anterior  wall,  which 
is  the  usual  fault,  the  patient's  head  must  be  elevated.  If  he  sees  one 
lateral  wall  or  the  other,  the  patient's  head  must  be  brought  to  the 
middle  line.  If  he  sees  the  posterior  wall,  which  is  a  very  rare  thing, 
indeed,  with  the  beginner,  the  head  may  be  lowered.  Of  course  these 
remarks  should  not  be  applied  too  strictly  to  cases  in  which  a  careful 
inspection  of  the  tracheal  wall  is  desired ;  but  even  in  such  cases  it  is  far 
better  to  examine  the  general  lumen  of  the  trachea  downward  before 
making  a  minute  inspection  of  the  lateral  wall,  because  it  is  only  by  keep- 
ing the  lumen  straight  ahead  that  one  can  determine  small  degrees  of 
compression  or  slight  amounts  of  such  diseases  as  perichondritis. 

In  passing  down  the  trachea  the  following  two  rules  must  be  kejJt 
in  mind  : 

1.  Before  attempting  to  enter  either  main  broueJnis  the  earina  iiutst 
be  identified. 

'2.  Before  entering  either  inuin  bronchus  the  orifices  of  both  should 
be  identified  and  inspected. 

These  are  time-saving  and  localizing  ex])edicnts  of  the  utmost  ini- 
])ortance.  For  quick,  accurate  and  efficient  work  the  bronchoscopist  must 
at  ail  times  know  exactly  the  particular  part  of  the  tracheo-bronchial  tree 
that  is  being  explored  by  the  tube-mouth.  With  a  natural  faculty  of 
orientation,  a  practical  working-knowledge  of  the  average  distances,  and 
familiarity  with  the  endoscopic  appearance  of  the  few  landmarks  this  is 
easy.  These  things  cannot  be  gained  from  a  book.  It  is  useless  to 
memorize  arbitrary  measured  distances.  The  practical  working-knowl- 
edge is  best  obtained  from  a  wet  anatomical  preparation  by  draining  out 
the  fluid  and  then  passing  the  bronchoscope,  studying  together  the  en- 
doscopic and  external  anatomy  of  the  dissected  tree  from  which  the 
lung  tissue  has  been  remo\ed  at  the  root  of  each  lung. 

In  doing  bronchoscopy  on  the  living,  after  the  laryngoscope  is 
removed,  the  bronchoscope,  which  was  held  in  the  right  hand  for  in- 
troduction, is  now  held  between  the  thumb  and  finger  of  the  left  hand, 
tile  second  and  third  fingers  of  which  are  hooked  by  their  terminal 
phalanges  over  the  upper  teeth  (Fig.  l.'iT  ).  This  steadies  the  hand  and 
any  desired  depth  of  bronchoscopic  insertion  can  be  maintained  indefinite- 
ly with  ease  and  accuracy  by  the  left  hand  alone.  This  serves  two  very 
im]:'ortant  purposes:  1.  The  exact  desired  relation  of  the  tube-mouth 
to  a  foreign  body  (or  tumor)  can  be  preserved  exactly  for  the  applica- 
tion of  the  forceps.     2.    The  right  is  free  for  the  [prompt  use  of  the  for- 


INTRODl'CTIOX  01'  TIIK   liRONCIIOSCOPE. 


167 


ceps,  as  soon  as  the  desired  tubal  position  is  established.  The  author 
believes  these  two  factors  contribute  largely  to  the  success  attending  work 
with  distally  lighted  tubes.  A  heavy  handlamp  prevents  this  anchoring 
of  the  tube  in  a  tixed  position  by  the  fingers  of  the  left  hand  on  the 
teeth.  Hence,  the  slightest  movements  of  the  patient,  e\en  the  respira- 
tory  movements,   may   disturb   the   relations   which   are   relied   upon   to 


Fir,.  I,?-. — The  heavy  laryngoscope  has  1)cen  removed  leaving  the  light  broncho- 
scope in  position.  The  operator  is  inserting  forceps.  Note  how  the  left  hand  of  the 
operator  holds  the  tube  lightly  between  the  thumb  and  first  two  fingers  of  the  left 
hand,  while  the  last  two  fingers  are  hooked  over  the  upper  teeth  of  the  patient 
"anchoring"  the  tube  to  prevent  it  moving  in  or  out  or  otherwise  changing  the  re- 
lation of  the  distal  tube-mouth  to  a  foreign  liody  or  a  growth  while  forceps  are 
being  used.  Thus,  also,  any  desired  location  of  tlie  tube  can  be  maintained  in  syste- 
matic exploration.  The  assistant's  left  hand  is  dropped  out  of  the  way  to  show  the 
operator's  method.  The  assistant  during  bronchoscopy  holds  the  bite-block  like  a 
thimble  on  the  index  finger  of  the  left  hand,  and  the  assistant  should  be  on  the 
right  side  of  the  patient.  He  is  here  put  wrongly  on  the  left  side  so  as  not  to  hide 
the  instruments  and  the  manner  fif  holding  tlicm. 


facilitate  the  accurate  application  of  the  forceps  by  sight.  After  an- 
choring the  bronchosco]je  with  the  fingers  of  the  left  hand,  the  riglit  is 
used  at  the  collar  of  the  proximal  end  (not  grasping  the  handle)  to 
manipulate  the  tube,  inward,  outward,  downward,  upward  or  laterally, 
the  tube  being  permitted  to  slide  between  the  finger  and  thumb  of  the 
left  hand,  if  withdrawal  or  deeper  insertion  is  needed.     At  any  time  it 


168  INTRODl^CTinx  OF  TltK  BRONCHOSCOPE. 

is  instantly  fixed  at  the  desired  point ;  for  instance  wiien  a  momentary 
view  of  a  foreign  body  has  been  obtained,  followed  by  disappearance  due 
to  respiratory  movement,  cough,  a  flood  of  secretions.  It  is  very  im- 
portant under  such  circumstances  to  keep  the  tube  there  until  an- 
other view  is  obtained.  The  manipulation  of  the  tube  with  the  right 
hand  is  important.  The  handle  of  the  bronchoscope  is  not  grasped  firmly 
in  the  clenched  hand  as  one  would  hold  a  revolver  (A,  Fig.  13S).  On 
the  contrary  it  is  held  lightly,  by  the  collar  with  the  right  thumb  and 
index  finger  (B,  Fig.  138)  the  other  fingers  either  not  being  used  at  all 
or  only  to  assist  in  rotating  or  balancing  the  instrument.  The  handle 
of  the  bronchoscope  is  needed  only  when  it  is  desired  to  rotate  the  bron- 
choscope, and  then  it  is  used  but  slightly,  being  pushed  around  with  the 
second  and  third  fingers  of  the  right  hand  while  the  thumb  and  index 
finger  hold  the  collar. 


A  B 

Fig.  138. — A,  incorrect  manner  of  holding  bronchoscope.  The  grasp  is  too 
rigid  and  the  position  of  the  hand  is  awkward.  B,  correct  manner,  the  collar  being 
held  lightly  between  the  finger  and  tlie  thumb.  The  thumb  must  not  occlude  the 
proximal   tube   mouth. 


Identification  of  the  normal  carina  is  easy  when  the  orifices  of  both 
main  bronchi  are  exposed.  The  difficulty  which  beginners  have  is  due 
to  the  fact  that  the  right  bronchus  is  mori^hologically  the  continuation 
of  the  trachea  whereas  the  left  is,  in  many  cases,  for  endoscopic  pur- 
poses, a  lateral  branch.  Hence,  special  care  must  be  taken  in  searching 
for  the  carina  to  pass  down  the  trachea  with  the  lip  of  the  bronchoscope 
toward  the  left  (A.  Fig.  139)  and  to  make  slight  lateral  pressure  with 
the  lip  of  the  bronchoscope  on  the  left  tracheal  wall,  while  the  head  of 
the  patient  is  held  slightly  toward  the  right.  This  will  result  in  exposing 
the  left  main  bronchial  orifice  and  between  it  and  the  right  is  the  carina, 
which  by  this  method  should  never  be  missed.  If  some  detail  is  neg- 
lected and  the  left  bronchial  orifice  is  not  in  evidence,  it  is  only  neces- 
sary to  withdraw  the  bronchoscope   (not  too  far,  lest  it  be  brought  al- 


INTKOnUCTlOX  OF  THE  BRONCHOSCOPli. 


169 


together  out  of  the  trachea)  and  to  start  over  again.  Occasionally  a 
diseased  condition  of  the  carina  may  cause  difficulty  in  identification,  as 
in  ulceration,  excessive  deformity  from  the  pressure  of  a  mass  of  medias- 
tinal lymph  nodes,  etc.  In  such  cases  the  identification  of  the  bronchial 
orifices  can  be  made  by  careful  examination.  Anomalies,  such  as  the 
upper  lobe  bronchus  being  given  off  from  the  trachea,  might  cause  con- 
fusion though  in  the  only  case  of  this  anomaly  seen  by  the  author  the 
mistake  could  scarcely  have  been  made  because  the  orifice  was  found 
only  by  effort.  Kahler  has  observed  diverticula  of  the  trachea  but  these 
pouches  ought  not  to  lead  to  error  in  identification  of  the  carina. 


Fig.  1.39. — Schema  demonstrating  the  method  of  entering  the  desired  bronchus 
with  the  slanted  end  bronchoscope.  Recumbent  patient.  A,  entering  the  left 
bronchus.  B,  the  beak  being  reversed,  the  bronchoscope  naturally  linds  its  way 
into  the  right  bronchus.  The  head  of  the  patient  is  to  the  side  opposite  to  that 
of  the  desired  bronchus,  and  the  axis  of  the  trachea  consequently  is  given  a  posi- 
tion at  a  more  obtuse  angle  to  that  of  the  desired  bronchus  than  is  shown  in  this 
schema,  which  is  intended  to  emphasize  only  the  use  of  the  slanted  end. 


Entering  the  bronclioscof'e  into  the  right  and  left  main  bronchi.  If  it 
is  desired  to  enter  the  right  bronchus,  the  patient's  head  is  moved  to  the 
left  and  the  bronchoscope  is  maintained  in  the  same  position  as  when 
started,  namely,  with  the  handle  out  horizontally  to  the  right.  If  it  is 
desired  to  enter  the  left  bronchus,  the  patient's  head  is  moved  to  the 
right  and  the  handle  of  the  bronchoscope  is  placed  out  horizontally  to 
the  left.  The  purpose  of  turning  the  handle  in  these  directions  is  to 
bring  the  lip  of  the  bronchoscope  in  proper  position  to  facilitate  the  en- 
trance of  the  desired  bronchus,  as  will  be  understood  by  referring  to  the 
schema,  Fig.  13S). 


170 


INTRODUCTION  OF  THE  BRONCHOSCOPE. 


Entering  the  bronchoscope  into  the  middle  lobe  bronchus.  For  in- 
troduction, the  head  must  be  high  above  the  table  in  order  that  the 
trachea  shall  be  in  line,  as  previously  explained.  \Mien,  however,  it  is 
desired  to  enter  an  anterior  branching  bronchus,  like  the  middle  lobe 
bronchus,  which  is  usually  given  off  more  or  less  toward  the  anterior 
part  of  the  right  stem  bronchus,  below  the  giving  off  of  the  upper  lobe 
bronchus,  it  is  necessarv  to  lower  the  head  and  to  some  extent  the  shoul- 
ders of  the  patient,  as  seen  in  the  schema.  Fig.  140.  To  accomplish  this 
lowering,  it  is  necessary  to  have  the  shoulders  of  the  patient  well  out  in- 


TT 


Fic;.  140. — Schema  illustrating'  tlie  entering  of  tlie  antc-rinrly  lirancliing  middle 
lobe  bronchus.  T,  trachea.  B,  orifice  of  left  main  bronchus  at  bifurcation  of 
trachea.  The  bronchoscope,  S,  is  in  the  right  main  bronchus,  pointing  in  the  di- 
rection of  the  right  inferior  lobe  bronchus,  I.  In  order  to  cause  the  lip  to  enter  the 
middle  lolie  bronchus,  M,  it  is  necessary  to  drop  the  head  so  that  the  bronchoscope 
in  the  trachea  T  T,  will  point  properly  to  enable  the  lip  of  the  tube  mouth  to  enter 
the  middle  lobe  bronchus,  as  it  is  seen  to  have  done  at  ML. 


to  the  air  toward  the  operator.  The  ridge  of  the  patient's  scapulae  should 
be  at  the  edge  of  the  table.  This  will  give  the  widest  range  of  move- 
ment. In  entering  the  middle  lobe  bronchus  the  slanted-end  broncho- 
scope is  much  superior  to  any  other  shape  as  will  be  understood  by  look- 
ing at  the  schema,  Fig.  141. 

The  method  of  entering  the  bronchoscope  into  the  I'urioiis  branch 
bronchi  is  the  same  in  [jrinciple  as  the  entering  of  the  middle  lobe  bron- 
chus. That  is,  the  lip  of  the  slanted-end  bronchoscope  is  brought  to  the 
mouth  of  the  branch  bronchus  by  rotation  of  the  bronchoscope  until  the 


IXTRODIXTION   OF  TIIK  BRONCHOSCOPE.  I'i'l 

handle  corresponds  to  the  general  direction  of  the  branch  bronchus.  Then 
the  head  and  neck  of  the  patient  are  swung  to  the  opposite  direction  more 
or  less  strongly  as  needed.  The  bronchoscope,  which  has  been  kept  a 
little  above  the  orifice  of  the  branch  bronchus,  is  now  pushed  downward, 
the  lip  making  slight  pressure  on  the  wall  as  it  goes,  so  that  when  the 
mouth  of  the  branch  bronchus  is  reached,  the  lip  will  slip  in.  If  tlie 
orifice  cannot  be  thus  found,  the  reverse  method  may  be  used.  That  is 
the  bronchoscope  is  inserted  down  the  stem  bronchus  past  where  the 
orifice  must  be.  (  )n  withdrawal  the  lip  of  the  bronchoscope  is  pressed 
firmly  against  the  lateral  wall  so  that  when  the  orifice  is  reached  the  lip 
will  spring  into  the  orifice,  or,  rather,  the  ridge  corresponding  to  a 
carina  will  suddenly  appear  in  the  endoscopic  image.  This  reverse  method 
is  especial!)-  undesirable  in  foreign-body  cases  because  the  foreign  body 
may  be  pushed  farther  into  the  branch  bronchus. 

Biitcring  the  bronchoscope  into  the  upper  lobe  bronchus  is  done  by 
the  method  just  described,  the  maneu\er  being  facilitated  by  moving  the 
tube  to  the  corner  of  the  mouth  opposite  to  the  side  of  the  desired  bron- 
chus, and  by  displacing  the  head  an<l  neck  far  down  to  this  opposite  side, 
also  Ix'ing  careful  to  have  the  li[)  of  the  brunchoscope  in  the  proper 
direction  (Fig.  HI).  If  it  is  remembered  that  the  fulcrum  of  the 
bronchoscopic  lever  is,  or  should  be,  the  upper  thoracic  aperture  ( Fij?- 
135)  there  need  be  no  difficulty  in  entering  the  stem  of  the  upper  lol)e 
bronchus  of  either  side  (Fig.  111).  A  greater  depth  is  explorable  on 
the  right  than  on  the  left  side.  It  is  not  possible  to  get  a  lumen  image, 
but  the  short  stem  can  be  entered  as  far  as  the  giving  ofif  of  the  first 
branches,  and  this  is  the  part  in  which  foreign  bodies  are  most  likely 
to  lodge.  Even  in  this  location  they  are  exceedingly  rare.  There  is 
no  need  of  tracheotomy  for  exploration  of  the  up])er  lobe  bronchus 
because  no  more  of  it  can  be  explored  by  thai  route  nor  is  it  more  easily 
thus  entered,  as  exi)laine(l  on  a  future  page  in  discussing  the  relative 
merits  of  oral  and  tracheotomic  bronchosco])y.  The  limitations  are  fixed, 
not  by  the  larynx,  but  by  the  upper  thoracic  aperture.  The  orilice  of  the 
up])er  lobe  bronchus  on  the  left  side  may  be  looked  for  at  about  4  cm. 
after  passing  the  bifurcation.  (  )n  the  right  side  it  may  be  1  cm.  or  "^  cm. 
from  the  Ijifurcaticn,  but  it  should  be  looked  for  at  once  after  entering 
the  right  main  bronchus.  In  estimating  desired  depths  of  insertion,  the 
quickest  method  is  to  move  the  finger  and  thumb  of  the  left  hand  up  on 
the  tube  the  required  distance  from  the  teeth.  Then  the  tube  is  in- 
serted until  the  tlnmib  and  finger  are  felt  to  reach  the  teeth.  This  seems 
simple,  easy  and  (|uickly  done  as  compared  to  reading  numbers  in  a 
darkened  room ;  but  many  operators  prefer  to  read  off  the  graduation 
marks  on   the  outside  of  the  tube  and   the  endoscopist  may  choose   for 


1T3  INTRODUCTION   OF  Tllli  BRONCHOSCOPE. 

himself.     The  author  never  uses  either  method,  preferring  to  gauge  the 
depth  by  the  endoscopic  image  as  the  tube  is  advanced  or  withdrawn. 

Bronchoscopy  in  children.  The  technic  of  bronchoscopy  in  children 
is  precisely  the  same  as  just  described  for  the  recumbent  position  in 
adults.  The  author  of  late  years  has  not  used  any  anesthetic,  general 
or  local,  for  children  under  six  years  of  age.  This  increases  the  diffi- 
culties somewhat,  yet  it  brings  the  risk  of  bronchoscopy  down  to  noth- 
ing, eliminates  complications,  and  it  has  the  advantage  of  rapidly  get- 
ting rid  of  secretions.  The  recumbent  position  is  best,  in  the  author's 
opinion,  for  reasons  already  herein  given.  One  precaution  necessary  in 
children  is  to  see  that  they  do  not  arch  up  the  chest.  If  they  do,  the 
nurse  who  holds  the  two  hands,  uses  her  right  hand  to  press  the  chest 


Fig.  141.— Schema  illustrating  the  advantage  of  the  slanted-end  bronchoscope 
for  entering  branch  bronchi,  especially  the  upper  lobe  bronchus.  When  the  squarely 
cut  off  bronchoscope  (e)  is  lowered  to  the  most  advantageous  angle  possible,  as 
shown  by  the  dotted  lines,  the  mechanical  difficulty  is  still  great  as  compared  to 
the  slanted-end  bronchoscope  as  shown  by  the  dotted  lines  (/). 


gently  down  on  the  table,  without  letting  go  tlie  left  arm  of  the  child, 
carrying  the  child's  arm  witli  her  hand.  Children  are  particularly  sub- 
ject to  subglottic  edema,  especially  if  too  large  a  tube  be  used,  or  the  be- 
fore-mentioned precautions  to  avoid  the  fulcral  pressure  on  the  larynx 
are  neglected.  In  addition,  of  course,  all  of  the  niceties  of  bronchoscopy 
must  be  practiced  in  the  bronchoscopy  of  children,  because  of  the  delicacy 
of  the  tissues.  The  4  mm.  tube  should  be  used  as  a  rule  for  infants  un- 
der about  ten  months.  The  author  uses  it  for  one  year  and  under.  The 
author  has  special  forceps  for  the  i  mm.  tube.  These  forceps  can  be 
seen  to  close;  and  all  of  the  manipulations  in  foreign-body  extraction 
can,  and  should  be,  done  under  the  guidance  of  the  eye.    Brimings'  state- 


INTKOUUCTION   01-    THE   ISROXCIIOSCOPE. 


173 


Fic.  1-1-'. —  bronchoscopy  by  BriiniiiKS  nicthoil.  The  laryiiKoscopic  tube  is  intro- 
duced through  tlie  glottis  with  the  riglit  Iiand.  Then  the  inner  tu1)C  is  inserted  with 
the  left  hand,  as  shown  in  the  upjier  illustration.  When  forceps  or  other  instru- 
ments are  to  be  used  the  laryngo-bronchoscope  is  transferred  to  the  left  hand  as 
shown  in  the  lower  illustration. 


174  INTRODUCTION  OF  THK  BRONCHOSCOPE. 

ment   that   ocular  guidance   "'is   largely   an   illusion"   can   refer   only   to 
proximally  lighted  tubes. 

Introduction  of  the  Bri'tnings  bronchoscope.  The  introduction  of  the 
Briinings  bronchoscope  is,  in  principle,  precisely  the  same  as  just  de- 
scribed up  to  the  exposure  of  the  glottis.  At  this  point,  the  distal  end  of 
the  Bri.inings  laryngoscope,  which  is  intentionally  small  for  this  very  pur- 
pose, is  itself  pushed  through  the  glottis  into  the  trachea,  then  the  bron- 
choscopic  extension  inner  tube  is  inserted  and  pushed  down  the  required 
distance  and  locked  with  the  ratchet,  shown  in  Fig.  4.  In  order  to  pre- 
vent loss  of  time  in  cleaning  the  mirror,  Briinings  advises  that  every 
time  the  patient  is  about  to  cough,  the  mirror  carrier  should,  if  possible, 
be  swung  to  the  operator's  left  side.  The  Briinings  method  differs  from 
that  of  the  author  in  the  uses  of  the  operator's  hands  as  shown  in  Fig. 
143.  The  operator  protects  the  lips  with  the  left  hand,  while  introducing 
the  laryngoscope  grasped  with  the  right  hand.  The  epiglottis  is  identi- 
fied, the  tip  of  the  laryngoscope  is  inserted  beyond  it,  but  not  too  far, 
as  previously  described.  Then  the  epiglottis  is  lifted,  ( recumbent  pa- 
tient) and  the  glottis  is  exposed.  As  before  explained,  under  no  cir- 
cumstances should  any  attempt  be  made  to  expose  the  glottis  until  the 
epiglottis  has  been  identified,  nor  should  any  attempt  be  made  to  insert 
the  instrument  through  the  glottis  until  the  cords  are  seen  and  identi- 
fied with  certainty,  in  at  least  their  posterior  third.  Briinings  con- 
siders it  not  absolutely  necessary  to  wait  for  the  complete  abduction  of 
the  cords,  as  the  beak  of  the  instrument  can  be  pushed  through,  if  the 
instrument  is  exactly  in  the  middle  line.  In  difficult  cases  digital  coun- 
terpressure  externally  on  the  larynx  may  be  used  to  assist  in  exposing 
the  cords  ;  and  in  cases  of  incomplete  anesthesia  the  instrument  may  be 
rotated  so  as  to  insert  the  wedge-shaped  beak  of  the  laryngoscope  in  the 
long  axis  of  the  glottis.  Having  inserted  the  laryngoscopic  tube  into  the 
trachea  with  the  right  hand,  the  inner  sliding  tube  is  inserted  with  the 
left  hand  (Fig.  143).  The  laryngoscope  is  not  removed  as  the  bron- 
choscopic  tube  slides  in  at  a  close  fit  and  becomes,  when  locked  with 
the  ratchet  shown  in  Fig.  4,  a  rigid  part  of  the  laryngoscope  itself.  When 
it  is  desired  to  use  forceps,  swabs,  aspirator  or  other  instrument,  vhe 
laryngo-bronchoscope,  which  up  until  this  stage  has  been  held  in  the 
right  hand,  is  now  transferred  to  the  left  hand  so  that  the  right  is  free 
for  the  use  of  forceps  as  shown  in  Fig.  142.  Briinings  states  that  when 
insurmountable  obstacles  to  the  passage  of  the  instrument  are  encoun 
tered,  it  is  usually  possible  to  succeed  by  putting  the  patient  on  his  left 
side,  with  the  head  supported.  Then  the  instrument  is  passed  as  in  the 
sitting  position.  He  states  that  he  occasionally  also  uses  the  ventral 
recumbent  position  which  he  finds  particularly  easy.     The  illustrations, 


INTKODVCTION   OF  THK   DRONCHOSCOPE.  I'J'S 

Fig.  142,  are  reproduced,  \>y  iicnnission,  from  Bninings'excellent  treatise. 
'•Die  direckte  Laryngoskopie,  Bronchoskopie  und  Esophagoskopie,"  of 
which  an  excellent  English  translation,  by  ^Ir.  Walter  G.  Howarlh,  is 
published  by  Messrs.  Bailliere,  Tindall  and  Cox. 

The  introduction  of  the  Kahlcr  bronchoscope  is  precisely  the  same 
as  just  described  for  the  P>runings  instrument. 

THK    NOKM.VL    BRONCHOSCOPIC    IM.\GE. 

In  the  author's  earlier  ])ulilication  (Bib.  209)  were  shown  a  number 
or  normal  and  pathologic  endosco])ic  illustrations  which  show  in  such  a 
satisfactory  way  the  living  appearances  that  no  new  colored  illustrations 
are  here  added. 

The  color  of  the  mucosa  as  seen  endoscopically  varies  with  the  degree 
of  illumination.  With  a  dull  glowing  filament  the  normal  mucosa  may 
seem  dark  red;  with  the  bright,  white  light  of  a  fully  illuminated  tung- 
sten filament  the  same  mucosa  will  seem  pinkish  white ;  while,  with  an 
over-illuminated  filament,  the  mucosa  may  seem  grayish  white.  The 
color  of  the  normal  mucosa  also  varies  with  the  anesthetic.  With  chlor- 
oform the  mucosa  is  paler  than  with  ether,  the  difference  being  due 
not  to  local  irritation,  but  to  the  engorgement  of  the  vessels  from  the 
general  stimulant  effect  of  ether.  Cocaine,  by  the  ischemia  it  causes, 
if  applied  before  the  bronchoscope  is  deeply  introduced  causes  the  color 
of  the  mucosa  to  appear  a  paler  pink,  .\drenalin  has  an  even  more 
marked  effect  in  whitening  the  endoscopic  image.  Neither  of  these  act 
to  the  same  extent  if  applied  after  the  bronchoscopic  examination  has 
coiuinued  for  some  time  in  the  examined  locality.  The  ridges  between 
the  orifices  of  branching  bronchi  are.  under  all  ordinary  conditions,  nor 
mally  of  a  glistening  whitish  color  with  only  occasionally  a  slight  tinge 
of  pink.  Their  color  often  leads  them  to  be  mistaken  by  the  beginner 
for  a  thread  of  mucus  or  a  foreign  body,  such  as  a  bright  pin. 

It  may  be  said,  then,  that  the  color  of  the  mucosa  as  seen  endoscop- 
ically, may,  in  health,  vary  from  almost  white,  through  yellowish  pink, 
bluish  ])ink,  pale  red  to  dark  red.  depending  upon  illumination  and  vas- 
cularity. 

The  form  of  the  endoscopic  picture  depends  upon  the  angle  at  which 
the  lumen  is  i)resented,  this  being  in  turn  dependent  upon,  (  1  )  the  ])osi- 
tion  of  the  tube,  and,  ( 2  )  the  position  of  the  parts  examined.  .\s  both 
are  constantly  changing,  the  variety  of  forms  in  the  eiuloscoiiic  picture 
is  almost  cntUess.  The  respiratory,  bechic,  pulsatory,  reflex  and  trans- 
mitted muscular  movements  and  compressions  so  modify  the  normal 
image  that   nothing  but   study  of  the  image,  as  seen   in   the  living,   will 


176  INTRODUCTION  OF  THE   BRONCHOSCOPE. 

educate  the  eye,  as  elsewhere  meiilioned.  When  the  axes  of  the  bronchial 
and  the  bronchoscopic  lumhia  exactly  correspond,  the  lumen  of  the 
bronchus  seems  to  diminish  more  or  less  concentrically  owing  to  per- 
spective, and  the  orifices  of  the  branch  bronchi  with  the  white  shining 
ridge  between  are  seen  beyond  (Fig.  143).  These  views  represent  com- 
plete images  which  are  momentarily  obtained.  Movements  of  the  vari- 
ous kinds  mentioned  are  constantly  hiding  the  orifices  and  ridges  that 
are  a  centimeter  or  more  beyond  the  tube-mouth.  These  are  accurately 
presented  images.  When  the  axis  of  the  bronchoscope  deviates  from 
coincidence  with  the  luminal  axis,  more  or  less  of  the  wall  toward  which 


Fig.  143. — Normal  endoscopic  images.  Semiscliematic.  i.  Left  main  bronchus. 
S,  left  upper  lobe  bronchus.  I,  left  inferior  lobe  bronchus  (or  "stem"  bronchus), 
showing  dorsal  and  ventral  branches.  2.  Right  main  bronchus.  SL,  superior  lobe 
bronchus.  M,  middle  lobe.  I,  lower  lobe  bronchus  showing  orifices  of  dorsal  and 
ventral  branches.  The  main  bronchus  (right  or  left)  below  the  upper  lobe 
bronchus  is  usually  referred  to  as  "stem"  bronchus  because  there  is  no  true  bifurca- 
tion, only  a  giving  off  of  lesser  branches  from  the  stem. 


the  tube-mouth  de\iates,  is  seen.  I'.y  the  form  and  position  of  the  rings 
seen  in  perspective  in  the  bronchial  wall  it  is  possible  to  estimate  how 
far  the  luminal  axis  deviates  from  the  bronchoscopic  axis,  and  thus  the 
direction  of  the  particular  branch  bronchus  may  be  estimated.  By  the 
same  means  the  proper  direction  in  which  to  move  the  tube  to  obtain  a 
view  directl)-  into  the  long  axis  of  the  lumen  is  known.  C)n  the  posterior 
tracheal  wall,  the  "party  wall.''  the  signs  of  rings  are  absent.  Else- 
where in  the  normal  trachea  the  ring-like  appearance  is  more  or  less 
marked  by  differences  in  color.  The  membranous  inter-spaces  are  usual- 
ly of  deeper  color  than  the  prominences  corresponding  to  the  cartilage. 


INTRODUCTION   OF  THE  BRONCHOSCOPE.  177 

If  tlie  tracheal  mucosa  is  edematous,  iuliltrated,  or  very  much  engorged, 
the  rings  may  nut  be  visible.  The  ringed  appearance  of  the  wall  dimin- 
ishes as  we  go  downward  untii  it  is  not  noticeable  in  the  smallest  bronchi, 
though  it  is  not  missed  because  the  orifices  make  more  or  less  of  a  ringed 
appearance  in  the  endoscopic  image. 

The  posterior  tracheal  wall  is  ordinarily  somewhat  flattened  and  may 
even  assume  a  convex  form  as  it  bulges  forward  into  the  trachea  during 
cough,  especially  in  children  examined  without,  or  with  only  slight,  anes- 
thesia (Fig.  144).  In  addition  to  the  posterior  wall,  there  is  a  flattening 
often  visible  at  the  aortic  crossing  and  also  at  the  bifurcation,  these  being 
in  some  instances  continuous  with  each  other.     A  slight  flattening  in  the 


/^N 


Fic.  144. — Endoscopic  view  showing  forward  bulging  of  the  posterior  mem- 
branous tracheo-esophageal  wall  during  cough.  Patient  dorsally  recumbent.  Not 
patliological.  Seen  mostly  in  children,  and  accentuated  w-hen  the  bronchoscopic  tube 
mouth  bears  too  much  on  the  posterior  tracheal  wall. 

neck  at  the  level  of  the  thyroid  gland  cannot  be  called  pathological.  All 
of  these  flattenings  are  usually  from  before  backward,  though  the  longest 
diameter  of  the  tracheal  cross-section  is  seldom  exactly  in  the  lateral 
plane. 

The  orifices  of  the  dorsal  and  ventral  branch  bronchi  are  not  opposite 
each  other  in  the  stem  bronchus.  The  inferior  lobe  bronchi  in  some  cases 
end  in  a  sort  of  axis,  where  two  or  more  branches  are  given  off  at  nearly 
the  same  level,  which  is  in  contrast  to  the  nionopodic  branching  higher  up. 


CHAPTER     X. 

t 

Introduction  of  the  Esophagoscope. 

Indicailons  and  contraindicatiuns  for  esophagoscopy  will  be  consid- 
ered under  "Foreign  Bodies"  and  under  "Diseases."  The  remarks  there 
made  on  contraindications,  especially,  should  be  read  before  attempt- 
ing the  introduction  of  the  esophagoscope. 

Anesthesia  and  position  of  the  patient  for  esophagoscopy  have  al- 
ready been  considered  in  a  separate  chapter. 

NORMAL   NARROWINGS  OF   THE   ESOPHAGUS. 

He  who  contemplates  attempting  esophagoscopy  for  the  first  time 
should  fix  in  his  mind  certain  general  principles,  anatomical  and  mechan- 
ical, that  are  known  to  experienced  esophagoscopists,  but  which  have 
never  before  been  put  in  concrete  form  for  the  preliminary  study  of 
the  beginner.  These  may  be  classed  under  two  heads:  1.  The  normal 
narrowings  of  the  esophageal  lumen  as  seen  endoscopically.  2.  The  nor- 
mal direction  of  the  esophageal   lumen,   esophagoscopically   considered. 

The  esophagus  is  not  a  flaccid  tube  through  which  an  endoscopic  tube 
can  be  rudely  pushed.  Nor  is  it  a  straight  tube.  It  deviates  and  has  cer- 
tain narrowings,  some  of  which  are  constant  anatomic  decreases  of  lumen. 
Others  are  due  to  pressure  of  surrounding  structures  that,  viewed  endo- 
scopically, give  one  the  idea  that  the  esophagus  was  put  through  first, 
and  then  all  of  the  surrounding  structures  were  tamped  in  around  it  like 
the  stones  and  earth  around  a  post  in  a  post-hole.  Other  narrowings, 
and  these  are  the  most  troublesome,  are  the  spasmodic  ones,  due  to  the 
contraction  of  periesophageal  musculatures.  There  are,  also,  spasmodic 
contractions,  less  powerful,  of  the  circular  muscular  fibers  of  the  esoph- 
ageal wall  itself.  Mehnert  (Bib.  404),  in  a  very  elaborate  paper  on  the 
anatomy  of  the  esophagus,  describes  thirteen  physiological  constrictions 
in  the  esophagus.     The  esophagoscopist,  however,  will  usually  be  able 


INTRODITTIOX    Ol"    TlIK    KSOl'lI AGOSCOPE.  JTO 

to  demonstrate  but  five.  1.  The  cricophaiyngeal  fold.  'L  The  crossing  of 
the  aorta.  3.  The  crossing  of  the  left  bronchus,  i.  The  hiatus  esophageus. 
r>.  The  upper  thoracic  aperture.  Some  esophagoscopists  beHeve  in  a  con- 
striction at  the  cardia  itself.  In  the  author's  opinion  there  is  certainly  no 
spliincter  at  the  cardia  and  he  cannot  but  think  that  the  constriction  noted 
by  some  observers  is  due,  in  some  instances,  to  the  intra-abdonilnal  pres- 
sure ;  in  others  to  mistaking  for  the  cardia  the  compression  produced  by 
the  narrowing  of  the  hiatus  esophageus  through  the  action  of  the  diaphrag- 
matic musculature. 

These  narrownigs  are  largely  due  to  static  or  contractive  pressure  of 
surrounding  structures.  The  esophagus  itself  is  so  thin-walled  a  struc- 
ture that  its  narrowings,  even  under  spasmodic  contraction  of  its  own 
musculature,  are  of  less  endoscopic  importance  than  the  peri-esophageal 
musculature,  are  of  less  endoscopic  importance  than  the  periesophageal 
structure.  It  is  elsewhere  stated  that  it  is  necessary  to  relax  the  eso- 
phageal musculature  in  order  that  trauma  be  not  done  during  the  extrac- 
tion of  a  very  large  and  sharp  foreign  body.  It  is  true  that  the  con- 
tractions of  the  esophageal  musculature  are  sufficient  to  permit  of  its 
laceration  b\-  the  withdrawal  of  a  foreign  body  when  the  musculature 
is  spasmodically  contracted,  yet  it  is  the  surrounding  musculature  acting 
upon  the  surrounding  hard  and  soft  parts  adjacent  to  the  esoi)hagus  that 
is  in  large  part  res])onsiblc  for  trauma  in  the  willulrawal  ul  foreign 
bodies  as  well  as  fur  the  iliflicullies  in  the  introduction  of  ihe  esoph- 
agoscope. 

The  cricopliaryih/cal  cuiislriclio)!.  In  a  previous  chapter  it  was  stated 
that  a  knowledge  of  endoscopic  anatomy  cannot  be  learned  from  books  ; 
and  to  a  certain  extent  it  cannot  be  learned  from  the  cadaver.  No- 
where is  this  better  exeni[)lilied  tiian  in  the  study  of  tile  cricopharyn- 
geal  constriction  of  the  espohagus.  In  the  cadaver  this  constriction  is 
widely  open  ;  and  prior  to  the  days  of  cso])hagoscopy  it  was  supjiosed 
to  be  open  in  life.  This  has  been  called  tiie  "mouth'"  of  the  esophagus: 
but,  as  by  the  ''mouth"  of  the  esophagus  esophagoscopists  do  not  refer 
to  the  crescentic  crevice.  (Tig  1,  I'late  III)  visible  by  direct  or  indirect 
laryngoscopy  back  of  the  arytenoid  eminence  and  aryepiglottic  folds, 
where  these  meet  the  postero-lateral  pharyngeal  wall,  much  confusion 
might  result  and  the  author  ])roposes  the  term  "cricopharyngeal  con- 
striction." This  crevice  is  the  entrance  to  the  hypopharynx  which  ends 
below  (in  the  unanesthetized  living  subject)  in  a  physiological  narrow- 
ing, which,  in  life,  looks  as  tliough  it  were  being  drawn  togctiicr  inter- 
mittently by  a  purse-string  outsi<le  the  esoiihageal  wall.  This  narrow- 
ing, in  the  adult,  is  about  two  centimeters  in  extent  and  is  noticeable  Imtli 
on   introduction   and    withdrawal   of   the   esophagoscope.      As   this   con- 


180  INTRODUCTION   OF   THE   ESOPHAGOSCOPE. 

striction  is  more  or  less  circular,  though  muscularly  incomplete  anterior- 
ly, it  might  be  called  a  sphincter;  but  this  is  objectionable  because  some 
esophagoscopists  believed  in  a  sphincter  at  the  cardia  and  spoke  of  "up- 
per and  lower  sphincter."  As  the  author  has  demonstrated,  the  lower 
constriction  is  at  the  hiatal  level — not  at  the  cardia.  Therefore,  the 
author  suggests  as  a  more  accurate,  and  hence  better,  nomenclature  "crico- 
pharyngeal  constriction"  and  "hiatal  constriction."  If  deemed  justi- 
fiable, a  "cardial  constriction"'  may  be  added.  Hut  true  sphincter  there 
is  none,  in  the  esophagus. 

The  lower  circular  bundle  of  fibers  of  the  inferior  constrictor  is  very 
powerful,  much  more  so  than  the  orbicular  fibers  of  the  esophagus  into 
which  they  merge.  (See  illustration  in  chapter  on  "DiverticuKuii  of 
the  Esophagus.")  The  median  raphe,  which  receives  the  insertion  of 
the  oblique  fibers  above,  is  wanting  below,  and  the  contraction  of  these 
circular  fibers  causes  the  greatest  diiiiculty  in  the  way  of  introduction 
of  the  esophagoscope,  and  it  is  the  one  thing  above  all  others  in  which 
continual  practice  is  necessary  in  order  to  acquire  skill  and  confidence. 
The  cricopharyngeal  constriction  and  the  fact  that  it  is  caused  by  the 
inferior  constrictor  were  recognized  by  Mikulicz  ;  but  it  remained  for 
Killian  to  demonstrate  that  only  the  circular  fibers  were  concerned,  and 
he  also  demonstrated  the  fact  that  there  is  a  weakly  supported  point 
between  the  fundiform  and  circular  fibers,  at  which  weak  point  the 
esophageal  wall  is  herniated  to  fomi  the  pulsion  diverticula  of  Zenker, 
as  illustrated  in  the  Section  on  Esophageal  Diverticulum.  The  author 
has  noted  in  two  instances  of  esophagoscopic  perforation  that  inex- 
perienced operators  had  pushed  the  esophagoscope  through  the  wall  at 
this  same  weak  point.  The  author  wishes  especially  to  emphasize  the 
vital  importance  of  these  two  observations.  (1)  //  the  esopha^/oscope  is 
allozved  to  follozv  its  natural  route  and  is  forcibly  pushed  downward  it 
will  certainly  perforate  this  z^rak  point,  into  zvhich  it  naturally  is  guided 
by  the  surroundiny  tissues.  {2)  This  tendency  is  to  be  combated,  in  the 
recumbent  position,  by  forcing  the  tube  mouth  anteriorly  (and  slightly 
medianwards)  zcith  the  left  hand,  as  soon  as  tin-  bottom  of  the  pyrifomi 
sinus  is  readied,  as  hereinafter  described.  The  constriction  at  the  mouth 
of  the  esophagus  is  to  a  great  extent  relaxed  under  profound  general 
anesthesia  ;  but  local  anesthesia  has  only  a  slight  relaxing  effect  upon  it. 
What  little  relaxation  there  is,  is  due  to  the  slight  lessening  of  reflex  ex- 
citability. No  endoscopist  expects  to  use  a  general  anesthetic  in  any 
but  exceptional  cases ;  and  children  should  not  have  either  a  local  or 
a  general  anesthesia  because  of  the  peculiarly  grave  risks  they  intro- 
duce into  esophageal  cases.     Therefore,  it  is  very  desirable  that  the  be- 


INTKnillTTlON    III"    Tin-;    KSOPII AGOSCOPE.  -181 

ginner  in  esophagoscopy   should  tirsl   devote  especial  preliminary   study 
to  the  upper  end  of  the  esophagus. 

The  best  method  of  studying  this  region,  in  health  or  disease,  is  with 
the  esophageal  speculum  (Fig.  -^1  )  used  gently.  It  requires  considerable 
force  to  pull  the  cricoid  forward.  Killian,  who  tried  it  on  a  tracheotom- 
ized  patient  b}-  means  of  a  hook  passed  through  the  tracheal  wound  and 
up  into  the  cricoid  ring,  described  the  resistance  as  '"enormous."  The 
h_\l)oiihar\-nx  was  watched  in  the  laryngeal  mirror  and  could  be  inspected 
but  the  mouth  of  the  esophagus  could  not  be  made  to  gape.  The  use  of 
the  esophageal  speculum  (Fig.  21  )  on  the  living  subject  and  on  the  cada- 
ver will,  by  contrast,  demonstrate  that  the  larynx  is  supported  in  position 
by  a  powerful  tonic  mustular  activity  in  life.  As  shown  by  Killian,  this 
muscular  tonicity  is  only  relaxed  by  central  impulses  such  as  in  degluti- 
tion, emesis  and  singing.  The  hypopharynx  can  be  studied  by  von 
Eicken's  method  of  hypopharyngoscopy.  The  larynx  is  cocainized  and  a 
stiff  steel  rod  bent  to  the  "laryngeal  curve"  of  indirect  instruments  and 
having  a  rounded  probe  poirit,  is  inserted  into  the  larynx  and  used  to 
pull  the  whole  larynx  forward,  while  the  hypopharynx  is  watched  in  the 
laryngeal  mirror.  This  in  favorable  cases  will  expose  the  hypopharynx 
down  to  the  level  of  the  middle  of  the  cricoid  cartilage.  This  cartilage 
usually  shows  whitish  under  the  mucosa. 

'J'lic  apcrtura!  iiarrozciiui  (if  the  t'sol^liuyiis  requires  experience  to 
demonstrate  esophagosco])icall.\',  but  is  amply  demonstrated  by  the  lodg- 
ment of  foreign  bodies.     (  See  Chapter  X\TI1. 1 

Tlic  aortic  nairowing  of  the  esophagus.  In  the  living,  the  mouth  of 
the  eso])hagus  will  seem  the  narrowest  part  of  the  esophagus  as  seen 
endoscopically  ;  but  in  the  cadaver  the  aortic  constriction  may  be  the 
narrowest  point  in  the  esophagus.  The  level  of  this  aortic  constriction 
is  determined  by  making  slight  pressure  with  the  tube-mouth  against 
the  left  anterior  wall  of  the  esophagus  when  the  actively  pulsating  aorta 
will  be  readily  palpated  with  the  tube.  Otherwise  the  aortic  narrowing 
nia\-  not  be  noticed  at  all  in  the  author's  "high-low"  method  of  esoph- 
agoscopv.  Faulty  positions,  by  compelling  faulty  tubal  direction,  may 
bring  the  aorta  into  conspicuous,  even  obstructive  prominence.  Thi.s 
is  esiiccialh'  true  of  a  Iciw  ln'ail  at  ibe  start,  as  in  the  Rose  position 
As  explained  later,  the  head  should  not  be  dropped  until  the  tube-mouth 
is  beyond  this  point.  The  normal  aortic  pulsation  usually  is  so  great  that 
the  beginner  is  apt  to  think  it  juithologic.  The  displacement  of  the 
esoi)hageal  wall  by  the  aorta  is  beautifully  shown  in  the  bismuth  radio- 
graphs re])roduced  in  the  Section  on  .Sj^asmodic  Stenosis.  The  aortic 
constriction  is  about  '-'•')  cm.    from  the  upi)cr  incisor  teeth   in   the  adnlt. 


182  INTRODUCTION   OF   THE   ESOPHAGOSCOPE. 

The  approximate  distance  in  children  is  given  in  the  author's  esophagos- 
copic  chart,  Figs.  14")  and  140. 

The  bronchial  narrowing  of  the  esophagus  is  due  to  the  backward 
displacement  caused  by  the  left  bronchus  which  crosses  anterior  to  the 
esophagus  at  about  27  cm.  from  the  upper  teeth,  in  the  adult.  The  ridge 
obsen'able  esophagoscopically,  Fig.  (S,  Plate  III,  is  quite  prominent  in 
some  patients,  esjjecially  those  with  dilatations  from  stenoses  lower  down. 
If  the  tube-mouth  is  made  to  bear  hrnilv  on  the  anterior  wall  on  the  way 
down,  the  ledge  corresponding  to  the  bronchial  crossing  can  be  made  to 
come  out  very  prominently. 

The  hiatal  narrox^-ing  is  both  anatomic  and  spasmodic.  The  eso- 
phagus is  narrowed  markedly  as  compared  with  the  suprajacent  eso- 
phagus :  and  the  peculiar  arrangement  of  the  tendinous  and  muscular 
structure  of  the  diaphragm  acts  on  this  hiatal  opening  in  a  way  to  con- 
strict it  most  powerfully.  Besides  this  there  is  a  local  musculature  demon- 
strated by  Liebault  (  Ijib.  33!) )  that  also  contributes  to  spasmodic  closure. 
The  level  of  the  hiatus  in  the  adult  is  about  'M\  cm.  from  the  upper  in- 
cisors in  the  extended  position  of  the  head.  The  approximate  distance 
in  children  at  various  ages  is  given  in  the  author's  esophagoscopic  chart 
Figs.  140  and  14(i. 

The  cardia  will  be  considered  under  the  head  of  spasmodic  stenoses. 

The  approximate  distances  of  the  esophageal  narrov\'ings  from  the 
upper  teeth  as  given  in  the  chart  (  Fig.  14-") )  are  necessarily  subject  to  in- 
dividual variation,  a  variation  witli  different  body-lengths  in  children  of 
the  same  age,  a  variation  with  posture,  coughing,  breathing,  retching, 
swallowing,  etc.  Moreover,  the  aorta  and  the  left  bronchus  are  rounded 
and  do  not  cross  at  a  right  angle  to  the  esophageal  axis.  For  all  of  these 
reasons  absolute  accuracy  is  impossible.  Therefore,  the  measurements 
were  made  to  read  in  even  centimeters.  Xotwithstanding  all  of  these 
variations  the  distances  given  will  Ijc  found  verv  useful,  practically,  and 
much  more  accurate  for  the  li\ing  than  cadaveric  tables.  The  chart  is 
arranged  as  the  operator  will  encounter  the  narrowings  on  the  way  down, 
with  the  patient  in  the  recumbent  position.  The  measurements  were  tak- 
en with  the  head  extended 

The  direction  of  the  esophagus  is  very  important  to  the  endoscopist 
for  on  a  thorough  knowledge  of  this  depends  the  easy  and  safe  intro- 
duction of  the  esophagoscope.  The  esophagus  enters  the  chest  in  a  di- 
rection decidedly  backward  as  well  as  downward  as  shown  in  the  schema 
(Fig.  04)  of  the  direction  of  the  trachea,  which  is  nearly  parallel,  the 
esophagus  lying  behind  the  trachea.  This  backward  direction  of  the 
esophag^is  is  maintained  as  though  the  esophagus  were  trying  to  get 
behind  the  aorta,  heart  and  left  bronchus.     Below  the  left  bronchus  the 


INTRODUCTION    OF    THE   ESOPHAGOSCOPE. 


183 


ly 


3^5 


6yrs 


Oyrs 


I4yrs. 


GHEATCR   curvature: 


LEFT  BRONCHUS     M      N 


CRICOPHARYINSEUS 


ESOPHAGOSCOPIC 

AND 

GASTROSCOPIC 
CHART 


■        '       ■ ■  ■  ^— "^ —• 

Fig.  145. —  The  autlior  s  esopnagoscopic  chart  ol  approximate  distances  of  the 
csophaReal  narrowinss  from  the  upper  incisors  prepared  by  the  author  from  meas- 
urements in  tlie  liviui;.  Arranged  for  convenient  reference  during  esophago^copy  in 
tin-  dorsally   recumbent   patient. 


184 


INTRODUCTION    OF    THR    ESOPHAGOSCOPE. 


ES0PHAG05C0PIC 

AND 

GA5TR05C0PIC 
CHART 


CRICOPHARVINGEUS 


AORTA 


LErT  BRONCHUS 


HIATUS 


GREATER   curvature: 


ADULTS  I4yr>,  lOyrs.    6yrs.    3yrs.    lyr.      BIRTH 


Fig.   146. — The  author's  esophagoscopic  chart  arranged   for   convenient   refer- 
ence in  the  sitting  or  laterally  recumbent  patient. 


INTRODUCTION    OK    THE    ESOPII AGOSCOPE.  185 

esophagus  turns  forward,  which  thrcction  it  maintains  until  it  passes 
through  the  liiatus  antl  reaches  the  stomach.  In  ackhtion  to  the  antero- 
posterior curvature  of  the  esophagus  just  descrihed,  there  is  a  lateral 
deviation  to  the  left  in  the  thorax,  which  partly  accounts  for  the  esoph- 
agus passing  back  of  the  left  bronchus.  The  other  part  is  accounted 
for  b\-  the  fact  that  the  trachea  deviates  slightly  toward  the  right  in  ap- 
proaching the  bifurcation  as  though  to  get  its  a.xis  more  nearly  in  line 
with  the  right  bronchus.  The  slight  deviation  of  the  esophagus  to  the 
left  in  the  middle  half  of  its  thoracic  portion  is  of  less  importance,  endos- 
copicallv.  than  the  very  marked  deviation  of  the  lower  esophagus  to  the 
left  before  and  after  passing  through  the  hiatus.  In  considering  the  an- 
teroposterior and  lateral  deviations  the  endoscopist  must  fix  in  his  mind 
that  the  esophagus  enters  the  chest  in  a  backward  and  downward  direc- 
tion (anatomically)  until  below  the  level  of  the  left  bronchus,  then  it 
curves  markedly  forward  and  to  the  left.  Mikulicz  thought  it  necessary 
to  put  an  angle  of  loO  degrees  in  his  esophagoscope  to  get  forward 
through  the  hiatus.  But  with  the  patient  in  the  ])Osition  developed  for 
the  author  by  Dr.  John  W.  Boyce,  the  patient's  anatomy  is  so  easily 
controlled  that  the  straight  and  rigid  esophagoscope  can  be  inserted 
through  the  hiatus  with  the  greatest  ease,  by  careful  attention  to  the  de- 
tails hereinafter  given  of  the  author's  "high-low"  method  of  esoph- 
agoscopy. 

Specular  csophagoscopy.  As  a  rule,  before  introducing  the  esoph- 
agoscope for  any  purpose,  the  hypopharynx  and  cricopharyngeal  con- 
striction should  be  inspected  carefully  with  the  speculum,  Fig.  21.  If  this 
be  not  at  hand,  a  fairly  good  inspection  can  be  made  with  the  laryngeal 
speculum.  This  is  necessary  for  growths  high  up  and  for  traumatism 
due  to  foreign  bodies  or  to  attempts  at  removal ;  or  the  foreign  body  it- 
self may  he  located  in  this  upper  region.  If  so.  it  may  be  overridden  by 
the  esophagoscope,  and  it  would  be,  in  any  event,  much  more  easily  re- 
moved through  the  esophageal  speculum.  Another  very  important  point, 
especially  in  children,  is  that  a  retropharyngeal  abscess  may  have  bur- 
rowed down  on  the  posterior  wall  until  it  has  produced  serious  difficulty 
in  swallowing ;  and  such  a  condition  might  easily  be  overlooked  with  the 
esoi)hagoscope,  though  plainly  visible  with  the  esophageal  s])eculum,  or 
with  the  direct  laryngoscope.  Of  course  dyspnea  is  much  more  apt  to 
be  a  symptom,  Init  the  author  has  seen  one  case  which  was  totally  free 
from  dyspnea,  the  child  being  brought  for  dysphagia. 

Technic  of  s(<ccular  csophagoscopy.  The  use  of  the  esophageal  spec- 
ulum (Fig.  21  )  is  precisely  the  same  as  direct  laryngoscopy  by  the 
method  described  for  the  author's  laryngoscope,  in  both  the  sitting  and 
recumbent  positions.     The  recumbent  position  is  preferable   for  reasons 


186  INTRODUCTION    OF    THE    ESOPH AGOSCOPE. 

previously  given,  and  for  foreign-body  work  is,  in  most  instances,  much 
more  certain  of  successful  extraction  of  the  intruder.  Secretions  are 
less  troublesome  to  the  operator  and,  by  not  overflowing  into  the  larynx, 
to  the  patient.  Children  are  more  easily  controlled,  no  anesthesia  being 
used,  as  elsewhere  explained.  Having  exposed  the  larynx  as  shown  in 
Fig.  1,  Plate  III,  by  the  method  shown  in  Figs.  78  and  92  (according  to 
whether  the  patient  is  in  the  sitting  or  the  recumbent  posture)  the  spat- 
ular  tip  of  the  esophageal  speculum  is  inserted  into  the  right  pyriform 
sinus  (left  in  the  sitting  patient).  From  now  on  downward  the  spec- 
ulum is  gently  insinuated  as  a  tube,  the  very  powerful  anterior  dis- 
placement necessary  for  direct  laryngoscopy  and  for  other  methods  of 
exposing  this  region  is  not  necessary  with  the  author's  speculum  because 
the  sloping  end  of  the  speculum  rides  forward  readily  with  a  slight  an- 
terior pull,  and  exposes  the  cricopharyngeal  constriction.  This  is 
readily  identified  with  the  speculum  by  the  anteriorly  convex,  crescent- 
shaped  fold  that  e.xtends  forward  from  the  posterior  hypopharj-ngeal 
wall  at  the  level  of  the  lower  third  of  the  cricoid  cartilage  (Fig.  3,  Plate 
III  ).  The  forward  projection  of  this  fold  hides  the  esophageal  lumen  be- 
low and  it  forms  a  chute  which  throws  forward  a  bougie,  esophagoscope 
or  other  instrument  causing  the  instrument  to  override  and  pass  the 
foreign  body  just  below  the  lip.  Strong  anterior  traction  on  the  larynx 
docs  not  open  the  lumen  any  wider  because  the  i)osterior  hypopharyngeal 
wall,  with  the  cricopharyngeal  folds,  follows  the  cricoid  forward,  the 
esophagus  remaining  closed.  In  Fig.  10,  Plate  III,  is  shown  the  manner  of 
drawing  back  this  posterior  fold  with  the  alligator  forceps,  exposing  a 
coin  wedged  in  the  esophagus  below  the  fold.  The  speculum  is  long 
enough  to  be  pushed  on  downward  flattening  the  fold  and  exposing  in  the 
open  trough  of  the  speculum  the  posterior  esophageal  wall  below  the  fold 
for  examination  or  operation.  A  careful  study  of  this  fold  and  its  chute- 
like action  must  be  made  with  the  speculum  to  be  understood,  because  the 
fold,  as  such,  is  not  so  noticeable  in  the  introduction  of  the  esophago- 
scope. though  the  obstruction  is  felt  very  markedly.  The  weak  point  in  the 
esophageal  wall  between  the  horizontal  and  oblique  fibers  of  the  inferior 
constrictor  is  just  at  the  proximal  base  of  this  fold,  and  if  the  angle  of 
introduction  is  bad  or  the  force  too  great  an  esophagoscope  will  not  be 
chuted  forward,  but  will  perforate  and  the  beginner,  strange  as  it  may 
seem,  does  not  discover  his  error.  He  passes  his  esophagoscope  on  down- 
ward with  little  resistance  between  the  layers  of  tissue  into  the  medias- 
tinum not  realizing  the  difference  between  the  walls  of  the  false  passage 
and  the  esophageal  wall.  In  one  such  case  the  author  was  asked  to  look 
through  the  esophagoscope  to  identify  a  shining  gray  membrane  that  was 
puzzling  the  surgeon  by  obstructing  the  way.    The  author  could  not  iden- 


INTRODUCTION    01"    TIIIC    ESOPH AC.OSCOPK,  187 

tify  the  membrane,  but  on  withdrawing  the  esophagoscope  the  layers  o£ 
connective  tissue  revealed  a  false  passage.  From  the  depth  of  insertion 
it  was  probable  that  the  membrane  w'as  the  pleura  though  no  post  mortem 
could  be  obtained.  There  was  extensive  emphysema.  Death  apparently 
was  due  to  vagitis  and  mediastinal  emphysema.  The  false  passage  began 
(B.  Fig.  15;3)  just  above  the  cricopharyngeal  fold. 

An  excellent  view  of  disease  of  the  posterior  wall  as  seen  through 
the  esophageal  speculum  is  shown  in  Fig.  9,  Plate  111. 

Technic  of  the  introduction  of  the  esophagoscope,  patient  recumbent. 
In  his  early  w-ork  the  author  used  a  mandrin  but  he  soon  found  that 
both  foreign  bodies  and  disease  might  be  overridden ;  therefore,  he  de- 
veloped the  technic  of  passing  by  sight  and  now  fmds  it  so  much  easier 
in  all  cases,  as  well  as  so  much  safer  in  disease  high  up,  and  so  invariably 
contributes  to  successful  foreign-body  removal,  that  he  would  not  con- 
sent to  the  use  of  a  mandrin  under  any  circumstances.  In  his  earlier 
work,  it  was  customary  with  the  author  to  apply  sterile  vaseline  to  the 
esophagoscope  before  passing.  Later  experience  has  proven  this  to  be 
unnecessary,  because  the  secretions  sufficiently  lubricate  the  instrument, 
and  it  is  f|uitc  a  relief  not  to  have  any  greasy  substance  about  the  in- 
strument table,  or  on  the  instruments  introduced. 

As  in  bronchoscopy  (Fig.  187)  the  esophagoscope  can  be  "anchored" 
at  any  desired  depth  by  hooking  the  phalanges  of  the  left  fourth  and 
fifth  fingers  over  the  jjatient's  upper  alveolus.  In  the  author's  method 
of  passing  the  esophagoscope  by  sight  fi\e  things  are  essential: 

1.     The  correct  "high-low"  position-sequence  of  the  patient. 

'i.  A  knowledge  of  the  endoscopic  anatomy  in  the  living  as  de- 
scribed in  this  chapter. 

.'i.  .-X  clear  conception  of  the  direction  and  changes  of  direction  of 
the  esophageal  axis  as  herein  given. 

4.  A  good  general  sense  of  direction  that  enables  the  endoscopist 
to  point  his  esophagoscope  in  the  general  direction  of  the  esophagus. 

•").  -^  clear  mental  image  of  the  esophagus  and  its  direction  in  re- 
lation to  the  esophagosco])e. 

\\  ith  these  (jualifications  the  endoscojiist  has  onl)-  to  follow  the 
landmarks,  to  be  able  (juickly  to  ])ass  the  esophagoscope  on  any  human 
being  whose  mouth  can  he  o[)ened.  The  introduction  may  be  divided 
into  four  stages. 

1.  ICntering  the  right  pyritorm  sinus. 

2.  Passing  the  cricopharyngeus. 

■i     Passing  through  the  thoracic  esophagus. 
1.     Passing  the  hiatus. 


188  INTRODUCTIOX    OF    TtlE    ESOPHAGOSCOPE. 

During  the  entire  iirocedure  the  patient  and  second  assistant  are 
in  the  Boyce  position  (Fig.  73),  the  second  assistant  holding  the  bite 
block.  During  the  first  and  second  and  third  stages  the  head  is  held 
high,  in  the  fourth  stage  it  is  dropped  until  the  occiput  is  slightly  below 
the  level  of  the  table.  Hence,  the  author  has  for  convenience  formed  the 
habit  of  calling  his  method  the  "high-low"  method  of  esophagoscopy. 

Stage  i.  Entering  the  pyriform  sinus  is  readily  understood  by  look- 
ing at  the  schema,  Fig.  147,  and  comparing  it  with  Fig.  1,  Plate  III.  The 
collar  of  the  tube  is  held  lightly  between  the  right  thumb  and  fingers  as 
shown  in  Fig.  B.  138,  and  the  tube-mouth,  guided  by  the  left  hand,  is  in- 
serted posterior  to  the  dorsum  of  the  tongue  and  with  the  proximal  end 
high  (Fig.  148).*  The  operator  standing,  his  eye  at  the  proximal  tube- 
mouth  seeks  the  right  pyriform  sinus.  (P.  Fig.  147,  and  Fig.  2,  Plate 
III).    The  landmark  is  the  right  arytenoid  eminence.  A,  Fig.  147,  which 


Fig.  147. — Schema  for  finding  the  pyriform  sinus  in  the  author's  method  of 
esophagoscopy.  The  large  circle  represents  the  cricoid  cartilage.  G,  glottic  chink, 
spasmodically  closed.  VB,  ventricular  hand.  A,  right  arytenoid  eminence.  P,  right 
pyriform  sinus,  through  which  the  tube  is  passed  in  the  recumbent  posture.  (Com- 
pare Fig.  I,  Plate  III.)     The  pyriform  sinuses  are  the  normal  food  passages. 

shows  as  a  rounded  mass  rather  larger  than  when  seen  by  the  indirect 
method.  (Seen  upward  to  the  left  in  Fig.  2,  Plate  III).  Great  care  must 
be  taken  to  identify  this  arytenoid  and  to  avoid  hooking  the  tube-mouth 
over  it  or  its  fellow.  This  would  prevent  further  insertion  and  if  force 
were  used  the  arytenoid  inobility  might  be  seriously  injured.  (A,  Fig. 
153).  Having  found  the  right  pvriform  sinus  the  tube  glides  in  readily 
for  2  or  3  centimeters  when  it  comes  to  a  full  stop  and  the  luiuen  dis- 
appears. This  is  the  spasmodically  closed  cricophar\ngeal  constriction. 
Buying  stage  i  or  any  of  the  other  stages  the  fingers  are  not  inserted  in 
the  mouth,  e.veept  to  far  as  neecssarx  for  the  "hool^inc/"  of  tlie  plialanges. 
(Fig.  137). 

Stage  2.     Passing   the   cricopharyngeus   is,    with    the   beginner,   the 
most  difficult  part  of  esophagoscopy,  especially  if  the  patient  is  unanes- 

*In  passing  the  slanted-enti  esophagoscope  (Pig:.  426)  in  the  recumbent  pa- 
tient, the  handle  of  the  e.«ophagoscope  must  always  point  toward  the  ceiling,  in 
order  to  bring  the  lip  of  the  esophagoscopic  tube-mouth  anteriorly,  so  as  to  ride 
over  the  cricopharyngeal  fold.  If  the  lip  is  posteriorward.  perforation  is  possible 
if  violence  be  u.sed. 


INTKODUCTIOX    OI"    THE    KSOPII AGOSCOPE. 


189 


thutized.  Local  anesthesia  does  not  help  much.  The  cricopharyngeus  as 
seen  through  the  esopiiagoscope  does  not  resemble  the  image  seen  in  the 
speculum  (Fig.  3.  Plate  III).  It  is  simply  a  lost  lumen.  Only  a  solid 
wall  of  mucosa  is  seen.  Force  must  not  be  used  but  a  steady,  firm  pres- 
sure is  made  on  the  esophagoscope  while  a  strongly  anterior  (lifting  in 
the  recumbent  position  )  movement  is  imparted  to  the  distal  end  of  the 
esophagoscope  by  the  left  harid.  At  the  same  time  the  lifting  motion  is 
imjiarted.   the   distal   end   should   be  guided   slightly   toward   the   middle 


Fig.  148. — Esophagoscopy  by  the  author's  high-low  method.  First  stage.  Find- 
ing the  right  pyriform  sinus.  In  this  and  the  second  stage  the  patient's  vertex  is 
ahoul  15  cm.  above  the  level  of  tlie  tabic  and  in  full  extension. 


line  of  the  body.  If  the  lumen  is  not  seen,  Ihc  [)alicnt  siuiuld  lie  told  to 
take  a  (lcc|i  brealh  when  the  lunun  will  tisualK-  ajipear.  In  an  unanesthe- 
tized  child  the  deep  inspiration  will  soon  be  made  involuntarily.  A  little 
patience  here  will  always  succeed.  The  author's  slanted-end  esoiihagoscope 
executes  this  second  stage  with  particular  ease,  the  lip  being  insinuated 
upward  and  forward,  and  the  handle  being  held  sagittaliy  and  anteriorly. 
The  lumen  is  a  mere  slit,  like  Fig.  4,  Plate  111,  though  the  axis 
of  the  slit  may  be  in  other  directions.  The  folds  at  the  sides  of  the  slit 
may  seem  to  bulge  toward  the  operator.  In  manv  instances  it  is  roselte- 
like  in  form  with  radial  folds;  and  it  varies  with  the  instrument  used. 


190 


INTRODUCTION   OF   THE   ESOPHAC.OSCOPE. 


There  is  usually  from  1  to  :!  cm.  of  this  constricted  lumen  at  the  level  of 
the  cricopharyngeus  and  the  subjacent  orbicular  esophageal  fibers,  after 
which  the  esophagoscope  glides  into  the  few  centimeters  of  partially  open 
cervical  esophagus.     (Fig.  5,  Plate  III). 

Stage  j.  The  esophagoscope  usually  glides  easily  through  the  thor- 
acic esophagus  (Fig.  150).  If  it  does  not  the  patient's  position  is  faulty 
or  the  esophagoscope  is  rubbing  on  the  upper  teeth.  The  levels  of  the 
aorta  and  left  bronchus  (Fig.  6,  Plate  III)  are  readily  recognized  by  the 
description  previously  given.  After  passing  them  the  lumen  of  the  eso- 
phagus seems  to  have  more  and  more  of  a  tendency  to  disappear  an- 
teriorly. This  is  the  signal  for  lowering  the  head,  which  has  till  now 
been  kept  high,  for  the  next  stage. 


NECK. 

Fig.  149. — Schematic  illustration  of  the  author's  "high-low"  method  o£  esoph- 
agoscopy.  In  the  first  and  second  stages  the  patient's  head  fully  extended  is  held 
high  so  as  to  bring  it  in  line  with  the  thoracic  esophagus,  as  shown  above.  The 
Rose  position  is  shown  by  way  of  accentuation. 


Stage  4.  Passing  the  hiatus  is  very  easy  after  a  little  practice  if  the 
directions  here  given  are  followed.  It  will  be  remembered  that  in  the 
first  part  of  this  chapter  the  direction  of  the  lower  esophagus  was  given 
as  anteriorly  and  to  the  left.  To  obtain  this  in  the  recumbent  patient 
the  head  is  dropped  as  shown  in  Figs,  l")!  and  l'^'i. 

When  the  head  is  dropped  it  must  at  the  same  time  be  horizontally 
moved  to  the  right  (withotit  rotation)  in  order  that  the  axis  of  the  eso- 
phagoscope shall  correspond  to  the  axis  of  the  lower  third  of  the  eso- 
phagus which  deviates  to  the  left.  The  shoulders  should  also 
participate  slightly  in  this  movement.  It  is  in  the  facility  of  making  these 
movements  that  one  of  the  great  advantages  of  the  Boyce  position  over 
the  lateral  or  any  other  position  for  esophagoscopy  consists ;  and  had  the 
author  not  had  the  advantage  of  "team  work"'  with  a  good  assistant  hold- 
ing the  patient  in  the  Boyce  position  he  could  not  have  developed  this 
"high-low"  method  to  its  present  approximate  perfection.     This  dropping 


iNTRonrcTioN  oi"  Tin-;  ksopiiacoscopk. 


191 


of  the  head  was  not  uiulcrslood  hy  Alikuhcz  ami  in  order  to  overcome  the 
angle  P  S,  Fig.  152,  he  put  a  htnd  in  his  gastroscope  thinking  that  he 
had  encountered  the  dorsal  spine  when  his  tube,  which  was  passed  blind- 
ly, encountered  the  resistance  of  the  diaphragm,  against  which  the  esoph- 
agus was  pushed  just  above  the  hiatus,  because  the  direction  of  the  tube 
was  faulty  owing  to  not  dropping  the  head.  Mikulicz  did  not  use  the 
dorsal  position  but  doubtless  he  would  have  obtained  an  equivalent  of 


Fig.  150. — Esophagoscopy  by  the  author's  "high-low"  method.     Stage  ,?.     Pass- 
ing thrcjiigh  the  thoracic  esophagus. 


dropping  the  head  had  he  been  possessed  of  a  modern  o]>en  tube  gas- 
troscope passed  by  sight.  The  hiatal  constriction  may  assume  the  form 
of  a  slit  or  more  commonly  a  rosette  (Fig.  7,  Plate  III),  and  in  its  ro- 
sette form  has  often  been  mistaken  by  esophagoscopists  for  the  cardia, 
leading  to  the  erroneous  idea  of  a  sphincter  at  the  cardia.  If  the  ro- 
sette or  slit  cannot  be  promptly  found,  as  may  be  the  case  in  various  de- 
grees of  diffuse  dilatation,  the  tube-mouth  must  be  shifted  farther  to  the 
left,  and  also  anteriorly.  I  f  the  tube-mouth  is  centered  over  the  hiatal 
constriction,  moderately  linn  i)ressure  continued  for  a  short  time  will 
cause  it  to  yield.     Then   the   tube,  maintaining  its  same  direction  will, 


192 


INTRODUCTION    OF    THE    ESOPHAGOSCOPE. 


witlKHit  further  trouble,  glide  into  and  through  the  abdominal  esophagus. 
The  cardia  will  not  be  noticed  as  a  constriction,  but  its  appearance  will 
be  announced  by  the  rolling  in  of  reddish  gastric,  mucosal  folds,  Fig.  8, 
Plate  III,  and  by  a  gush  of  fluid  from  the  stomach. 

The  normal  esophagoscopic  image.  The  form  of  the  endoscopic 
image  has  already  been  described,  as  seen  at  the  various  stages  of  esoph- 
agoscopy.  The  color,  as  in  all  the  mucosae,  is  subject  to  wide  individ- 
ual variations  within  the  limits  of  health,  though  not,  perhaps,  quite  so 
wide  as  is  seen  in  the  phar\nx.     The  color,  of  course,  varies  in  shade 


Fig.  151. — Esophagoscopy  by  the  author's  "hii;h-lii\v"  nu-thod.     Stage  4.     Pass- 
ing the  hiatus.     The  patient's  vertex  is  about  5  cm.  below  tlie  top  of  the  table. 


with  the  intensity  of  the  illumination,  being  dark  criinson  or  brown  un- 
der feeble  light,  nearly  white  under  the  intense  light  of  an  over-illumi- 
nated electric  lamp.  L'nder  ordinary  conditions  with  proper  illumina- 
tion it  may  be  described  as  pink  varying  from  yellowish  to  bluish  pink. 
As  the  author  has  pointed  out,  a  good  idea  of  average  color  may  be  had 
from  inspection  of  the  inside  of  the  particular  individual's  cheek  under 
the  same  illumination.  The  esophageal  mucosa  glistens  with  surface 
moisture.  The  folds  are  soft  and  velvety,  rendering  infiltrations  quickly 
noticeable.  The  cricoid  cartilage  usually  shows  whitish  through  the  mu- 
cosa.    As  soon  as  the  eye  becomes  educated  to  the  normal  appearance 


iNTKonrcTioN  (II"  Till-:  i:sopiiagoscope. 


193 


abnormalities  of  form  and  color  are  instantly  noted.  The  gastric  mu- 
cosa is  pink  if  no  food  is  present,  but  it  is  a  darker  pink  than  that  of 
the  esophagus.  When  food  is  in  the  stomach  the  color  is  crimson.  These 
colors  refer  to  distally  illuminated  images.  With  proximal  illumination 
the  color  is  said  to  be  dark  \ioIet.  probably  because  of  the  distance  from 
the  source  of  light. 

Difficulties  of  esof'luigoscof'y.  Those  who  follow  carefully  the  meth- 
ods herein  suggested  should  be  able  to  esophagoscope  an  average  patient 
under  general  anesthesia.  For  the  first  trial  of  esophagoscopy  without 
anesthesia  the  patient  should  be  a  slender  adult,  with  long  lean  neck  and 
lew  upper  teeth.  The  author  urges  every  endoscopist  to  avail  himself 
of  the  first  esophageal  case  of  this  type,  to  try  esophagosco[)y  without 
anesthesia.     Soon  be  will  find  it  needless  to  use  either  general  or  local 


Fig.  i-,2. — Srliematic  illustration  of  the  aiithor'.s  "high-low"  method  of  esoph- 
agoscopy, fourth  stage.  Passing  the  hiatus.  Tlie  head  is  dropped  from  tlie  po- 
sition of  tlie  I  St  and  2nd  stages,  CL,  to  the  position  T,  and  at  the  same  time  the 
head  and  and  shonklcrs  are  moved  to  the  right  (without  rotation)  wliich  gives  the 
necessary  direction   for  passing  the  hiatus. 


ane.ilbesia  for  esophagoscoiJN ,  and  be  will  have  many  occasions  to  be 
glad  that  he  has  ac(|uired  the  knack.  Cases  of  esophageal  malignancy 
quite  often  present  the  desired  qualities  mentioned,  and  many  of  them 
come  for  diagnosis  in  no  c(jndition  to  stand  an  anesthetic.  The  greatest 
difficulty  arises  from  the  faulty  direction  of  the  tube.  It  requires  a  gen- 
eral sense  of  direction  and  a  mental  picture  of  the  direction  of  the  esojjb- 
agus  within  the  body  ti>  get  ibe  lube  started  right  and  to  find  the  lumen 
of  the  pyriform  sinus  ami  of  the  eso])bagus  until  the  operator  bas  had 
sufficient  experience  to  know  the  landmarks  and  tlie  diflerent  appear- 
ance of  the    folds   of  niuciisa  as  be  proceeds.      In  order  tn   bring   these 


194  INTRODUCTION   OF  THE  ESOPHAGOSCOPE. 

into  view  it  is  necessary  to  remove  the  secretion.  In  the  author's  esoph- 
agoscope  this  is  taken  away  with  the  aspirator  without  interruption, 
though  occasionally  a  swab  may  be  useful  in  addition.  Stagnant  semi- 
solid food  in  stenotic  cases  is  best  removed  by  the  "sponge  pumping"  pro- 
cess as  described  for  bronchoscopy.  Another  great  difficulty  arises  from 
the  spasmodic  contractions  of  the  esophageal  musculature  and  especially 
of  the  inferior  constrictor  near  the  cricoid  level,  in  fact,  the  greatest 
difficulty  in  esophagoscopy  is  right  at  this  point.  This  and  the  hiatal 
spasm  are  to  be  overcome  by  patient  waiting  with  gentle  pressure  on  a 
correctly  directed  tube  centered  over  the  closed  lumen.  Forcible  misdi- 
rected pressure  may  perforate.  The  beginner  will  often  find  that  the 
esophagoscope  seems  to  be  rigidly  fixed  so  that  it  cannot  be  either  in- 
troduced or  withdrawn  readily.  Usually  this  comes  from  contact  with 
the  upper  teeth  of  the  patient  and  is  overcome  sometimes  by  a  little  wider 
opening  of  the  jaws,  and  sometimes  by  easing  up  on  the  bite  block,  but 
most  often  by  correcting  the  position  of  the  patient's  head.  If  the  be- 
ginner cannot  start  the  tube  into  the  right  pyriform  sinus,  in  an  adult, 
it  is  a  good  plan  to  insert  an  adult  direct  larj-ngoscope,  and  after  expos- 
ing the  arytenoid  eminences  to  view  to  insert  the  child  size  (7  mm.) 
esophagoscope  into  the  pyriform  sinus  by  sight.  This  is  one  of  the  best 
ways  to  learn  esophagoscopy.  The  side-slide  oval  laryngoscope  is  the 
best  for  this  purpose,  leaving  the  slide  ofi"  and  keeping  the  speculum  to 
the  right  (recumbent  patient)  side  of  the  tongue  so  that  the  tongue  will 
not  crowd  into  the  side  opening.  It  is  very  rarely  necessary  to  remove  an 
esophagoscope  once  it  is  inserted.  The  author  has  been  much  surprised 
to  learn  how  often  some  esophagoscopists  remove  and  reinsert  the  esoph- 
agoscope at  a  seance.  Once  in.  it  should  stay  until  the  esophagoscopy 
is  finished.  If  an  anesthetic  is  used,  it  may  be  necessary  to  remove  the 
esophagoscope  for  respiratory  arrest,  unless  insufflation  anesthesia  is 
used.  Without  anesthesia  no  accident  can  occur  in  careful  hands.  Oc- 
casionally it  is  necessarv'  to  remove  the  esophagoscope  to  exchange  it  for 
a  very  small  one  that  will  go  through  a  small  stricture  to  get  a  foreign 
body  that  has  lodged  between  two  strictures.  Occasionally,  especially  in 
stenotic  conditions  of  the  esophagus  a  large  quantity  of  fluid  will  well  up 
into  the  tube  and  it  will  be  thought  that  the  light  has  gone  out  because 
there  are  a  number  of  centimeters'  depth  of  opaque  fluid  over  the  light. 
As  soon  as  this  is  aspirated  through  the  drainage  canal  the  Hglit  will  be 
found  burning  as  brightly  as  ever.  If  in  doubt  as  to  whether  this  is  the 
case  the  light  carrier  may  be  withdrawn,  but  under  no  circumstances 
except  vital  dangers  to  the  patient  should  the  esophagoscope  be  with- 
drawn until  the  examination  is  complete.  As  the  author  uses  only  two 
sizes  of  the  esophagoscopic  tubes,  one  for  adults  and  one  for  children. 


IXTKODUCTION   OF  TIIIC  ESOPll AGOSCOPE.  195 

there  is  no  need  of  starting  with  the  wrong  size.  Serious  difficulties  may 
arise  from  insutticient  instrumental  e(|uipment,  and  unlike  other  depart- 
ments of  surgery  makeshifts  are  usually  impossible  and  may  be  dangerous. 
Xo  peroral  endoscojiic  attempt  should  be  made  without  proper  sized 
tubes  for  the  particular  case,  i)roper  forceps,  sponges,  batteries,  etc.  The 
operator  does  his  patient  and  himself  an  injustice  to  attemiil  endoscopy 
without  a  complete  set  as  to  sizes  of  whatever  form  of  tubes  he  desires  to 
use.  In  his  earlier  writings  the  author  stated  that  "If  rigid  economy 
must  he  ])racticed,  much  good  work  can  be  done  with  a  7  mm.x4."j  cm. 
esophagoscope,  a  ■'>  mm.x30  cm.  bronchoscope  and  a  12  mm.xlT  cm. 
laryngeal  speculum."  Bninings  has  very  justly  criticized  this  statement 
as  "likely  to  beguile  the  surgeon"  into  being  content  with  a  couple  of 
tubes  selected  at  random ;  and  he  further  states,  "An  insufficient  equip- 
ment is  often  worse  than  none  at  all.''  In  all  of  which  the  author  fully 
concurs. 

Moser  has  advocated  the  ballooning  of  the  esophagus  by  the  soft- 
rubber  hand-ball  of  an  atomizer,  the  air  being  prevented  from  escaping 
by  the  insertion  of  the  window-plug  (Fig.  20). 

In  conclusion  it  may  be  said  that  with  the  exception  of  inadequate 
ecjuipment  all  of  the  difficulties  of  the  introduction  of  the  esophagoscope 
are  overcome,  as  with  any  other  (nirely  manual  procedure,  bv  practice. 

Complications  following  csophagoscopx  for  foreign  bodies  will  be 
considerefl  in  a  later  chapter.  The  simple  passage  of  an  esophagoscope, 
if  skillfully  done,  is  rarely,  if  e\er,  followed  by  any  complications.  Slight 
stiffness  of  the  neck,  an<l  irritation  of  the  lower  pharynx  may  be  noted 
in  sensitive  subjects,  especially  those  with  siiorl,  thick  necks.  In  dis- 
eased conditions,  however,  we  may  have  complications  due  either  to  the 
esophagoscopy  or  to  the  condition  for  which  it  is  done.  Mr.  W'aggette 
(Bib.  5()7)  rei)orts  a  case  of  severe  dysfjhagia  following  esophagoscopy 
in  a  case  of  extensive  specific  ulceration.  It  would  seem,  however,  that 
the  dysphagia  might  have  resulted  from  the  disease  itself  willmut  ilic 
esophagoscopy.  Roth  contingencies  should  be  borne  in  mind,  and  a  pa- 
tient with  disease  of  the  esophagus  should  tie  lold  l)eforeliand  that  his 
ability  to  swallow  may  grow  worse  either  with  nr  witln'iu  an  esophagos- 
copy. These  remarks,  howe\fr.  do  not  ordinarilv  apply  to  recent  foreign- 
body  cases,  (lid  foreign-body  cases  may  be  followed  by  cicatricial 
stenosis.  If  esophagoscopy  is  to  maintain  the  high  position  of  usefulness 
it  has  attained  it  is  necessary  that  it  shall  be  safe.  If  the  rules  and  in- 
structions herein  given  are  followed,  esophagoscopy  is  absolutely  without 
mortality  aj^art  from  the  condition  for  which  it  is  done.  In  view  of  this 
tile  beginner  must  be  warned  to  be  careful.  The  accidents  shown  in 
r'ig.  1"):!  can  occur  only  through  brutal  disregard  for  the  delicacy  of  the 


196  INTRC)DrCTIC)X   01-    THK   KSOPHAr.OSCOPlC. 

esophageal  structures.  The  esophagus  is  surgically  the  most  intolerant 
organ  in  the  hody.  It  will  not  tolerate  anything  like  the  degree  of  oper- 
ative work  that  even  the  brain  can  stand.  This,  of  course,  is  partly  due 
to  the  fact  that  the  esophagus  is  a  septic  canal,  but  apart  from  sepsis,  as 
explained  in  the  second  part  of  this  book,  the  esophagus  is,  surgically, 
intolerant. 

Injury  to  the  cricoarytenoid  joint  (A.  Fig.  !')'.'> )  from  hooking  of 
the  tube-mouth  over  the  arytenoid  eminence  may  simulate  recurrent 
paralysis.  It  is  usually  due  to  traumatic  arthritis  or  myositis.  Posticus 
paralysis  may  occur  from  recurrent  or  vagal  pressure  by  a  misdirected 
esophagoscope.  Both  fixation  and  paralysis  usually  recover,  but  occa- 
sionally persist.  Perforation  of  the  esophageal  wall  and  false  passage 
has  already  been  alluded  to.     In  some  instances  fatal  septic  mediastinitis 


i^ 


Fig.  153. — Injuru's  truin  iorciijle  unskilled  attempts  at  usuijhagoscupy.  A. 
Fixed  right  arytenoid  injured  by  the  mouth  of  the  esophagoscope.  View  through 
direct  laryngoscope.  Recovery  followed.  B.  Opening  of  false  passage  just  above 
the  mouth  of  the  esophagus  at  the  site  where  diverticula  occur.  Fatal.  C.  Extrav- 
asated  blood  under  the  mucosal  epithelium  simulating  a  varicosity  or  angioma. 
Caused  by  undue  pressure  of  the  tube  mouth.  Probably  not  serious  but  indicative 
of  a  dangerous  amount  of  force.  D.  Exudate  covering  long,  gouged  area  resulting 
from  unskillful  esopha.goscopy.  Profound  shock.  Death  from  sloiigliing  sopha- 
gitis.     (Sketched  by  the  author  from  cases  seen  in  consultation.) 

has  occurred.  In  some  cases  which  have  come  to  the  author's  knowledge, 
])erforation  of  the  pleura  has  occurred.  In  all  such  instances,  the  au- 
thor would  advise  immediate  opening  and  drainage  of  the  pleura.  Pletiral 
shock  is  already  ]:)resent.  usually  pneumothorax  also.  All  such  cases  de- 
velop a  initrid  discharge,  having  the  odor  of  fecal  matter,  with  profound 
sepsis,  irritability  and  high  fever  unless  drained  promptly.  In  case  of 
septic  mediastinitis,  the  general  surgeon  should  be  consulted,  though  un- 
fortunately most  cases  are  hopeless. 

A  frequent  accident  with  the  beginner  is  the  gouging  of  a  bit  of 
mucosa  from  the  posterior  hypopharyngeal  wall.  This  comes  from  one 
or  more  of  three  errors:  (1)  Faulty  position  of  patient,  (2)  faulty  di- 
rection of  the  tube,  and  (3)  undue  haste  to  advance  the  tube  instead  of 
waiting  for  the  stihsidence  of  cricopharyngeal  spasm.     Patients  with  ad- 


INTRODTTIION   Ol-    i' 1 1 1:   ICSOIMI  Ai'DSCOPK.  197 

vaiiced  organic  disease  such  as  hard  arteries,  cirrhosis  of  the  Hver,  ad- 
vanced tuberculosis,  uncompensated  heart  lesions,  etc.,  may  have  se- 
vere complications  precipitated  by  esophagoscopy.  A  child's  esophago- 
scope  (  7  mm. )  skillfully  passed  with  high  head  will  involve  the  least 
risk  in  such  cases. 

J'lic  tcclniic  of  introduciiui  the  Kahler  csophagoscopc  is  precisely 
the  same  as  that  of  the  Hriinings  esophagoscope. 

Introduction  of  the  Brnnings  esophagoscope.  Britnings  describes 
two  methods  of  introduction,  one  with  a  mandrin  and  one  without,  the 
former  the  easier,  the  latter  the  preferable  way,  Briinings  advises 
ocidar  introduction  when  mandrin  introduction  involves  special  dangers 
or  fails  to  accomplish  the  object  for  which  the  esophagoscopy  is  done. 
He  believes  that  ocular  introduction,  therefore,  is  indicated  in  the  ma- 
jority of  cases.  Itninings  ])refers  the  sitting  position  of  the  patient, 
though  he  also  uses  the  laterally  recumbent  position  with  knees  flexed. 
In  either  position  the  patient's  head  is  held  by  an  assistant.  Occasionally 
he  uses  the  dorsally  recumbent  position,  but  he  regards  this  as  more 
difficult,  and  in  children  he  states  that  "Lying  on  the  back  must  in  any 
case  be  avoided."  He  states  that  a  general  anesthetic  is  always  neces- 
sary in  children  and  that  they  must  be  raised  up  for  the  introduction 
of  the  tube  after  they  are  anesthetized.  In  adults  thorough  local  anes- 
thetization with  cocaine  is  used.  The  ISrunings  tubes  should  be  warmed 
and  greased  with  licjuid  petrolatum  and  the  mirror  shoidd  be  warmed 
to  prevent  fogging  from  condensation.  In  introduction  of  the  esophago- 
scope with  the  mandrin,  the  hand  lamp.  Fig.  2.  is  detached  ;  the  funnel- 
shajied  [jroximal  end  of  the  tube  is  held  between  the  thumb  and  linger 
of  the  right  hand  like  a  ])en.  The  silk  wo\en  mandrin  projecting  be- 
yond the  distal  end  of  the  tube  is  ])assed  down  along  the  posterior 
pharyngeal  wall  into  the  esophagus.  If  the  mandrin  deviates  into  either 
pyriform  sinus,  Briinings  directs  the  patient  to  swallow  to  centralize  the 
tube  again.  When  the  reflex  contractions  at  the  esophageal  mouth  stop 
the  advance  of  the  mandrin  and  instrument,  no  violence  is  to  be  used. 
Instead,  an  in-and-out  ])rol>ing  niovenient  of  the  tube  is  used  and  llie 
patient  is  commanded  to  continue  regular  breatiiing.  and  to  swallow.  If 
introduction  fail,  it  is  necessary  to  wait  with  the  tube  and  mandrin  in 
position  until  the  spasm  relaxes.  This  is  known  by  the  sensation  of  an 
easy  advancing  of  the  tube  to  slight  pressure,  and  by  the  fact  that  the 
"spatula  tube"  of  the  inslnmient  almost  (lisai)i)ears  in  the  moiuh.  Then 
the  [jatient  bends  the  head  farther  backward  and  the  itroximal  portion 
of  the  tube  is  moved  around  to  one  corner  of  the  patient's  mouth,  the 
head  being  slightly  turned  to  the  o])posite  side.  If  a  gap  between  teetli 
is  available  the  tube  is  moved  into  the  gap.     Then  the  mandrin  is  re- 


198  INTRODUCTION   OF  THE  ESOPHAGOSCOPE. 

moved,  the  hand  lamp  attached  and  the  inner  tube  inserted.  If  the  latter 
has  been  in  place  with  the  mandrin  inside  of  it,  it  is  now  pushed  down- 
ward. In  most  instances,  however,  foreign  bodies  and  disease  high  up 
are  dealt  with  through  the  spatula  tube  alone,  without  using  an  inner 
tube. 

In  introduction  by  sight  in  the  sitting  patient  the  procedure  is  as 
described  for  direct  laryngoscopy  up  to  the  point  of  exposing  the  larynx, 
the  hand  lamp  being  fitted  with  the  tube  spatula  as  shown  in  Fig.  2. 
This  will  reach  to  the  level  of  the  tracheal  bifurcation.  If  it  is  desired 
to  explore  further,  the  inner  tube  (  Fig.  4 )  of  appropriate  size  and  length 
according  to  the  patient  is  inserted.  After  exposing  the  larynx,  the 
spatular  end  of  the  tube  spatula,  or  outer  tube,  is  inserted  in  the  median 
line  and  the  larynx  is  drawn  forward  as  the  spatular  end  is  slid  down 
behind  the  larynx  into  the  hypopharynx.  Here  the  advance  is  usually 
opposed  by  spasm,  bringing  the  posterior  lip  of  the  esophageal  mouth 
forward  and  presenting  an  "unconquerable  barrier"  to  further  advance. 
While  waiting  for  the  spasm  to  subside  the  position  of  the  patient  and 
of  the  instrument  are  inspected  to  see  that  they  are  correct,  with  relaxed 
muscles,  without  rigid  bending  of  the  head ;  and  the  patient  is  told  to 
keep  on  breathing  quietly  and  regularly.  Swallowing,  if  the  patient  can 
accomplish  it.  helps  materially.  Rotating  movements  of  the  tube  are 
helpful  in  finding  the  lumen.  Once  past  the  constriction  at  the  mouth  of 
the  esophagus  the  tube  passes  without  further  difficulty,  the  head  being 
managed  as  before.  When  the  full  length  of  the  spatular  tube,  or  outer 
tube,  has  been  inserted,  which  will  bring  the  distal  end  to  about  the 
level  of  the  tracheal  bifurcation,  the  inner  extension  tube  is  inserted  if 
it  is  desired  to  explore  further.  In  the  left  laterally  recumbent  patient 
the  manipulations  are  the  same  as  in  the  sitting  patient,  because  with  the 
operator  standing  facing  the  patient,  and  bending  the  operator's  head 
down  to  the  right,  the  operator  maintains  the  same  relative  position  to 
the  patient's  anatomy  as  in  the  sitting  position  of  the  patient.  In  the 
dorsal  position  of  the  patient  which  Briinings  does  not  advise,  the  oper- 
ator holds  the  instnmient  with  the  right  hand  as  in  Fig.  142.  For  fur- 
ther details  of  Briinings'  methods  the  reader  is  referred  to  Briinings'  in- 
teresting and  instructive  book  (Bib.  62)  or  to  the  excellent  translation 
thereof  by  Mr.  Walter  G.  Howarth  (Bib.  208). 


CHAPTER     XI. 

Acquiring  Skill. 

The  purpose  of  this  book  is  to  tell  how  to  do  peroral  endoscopy. 
But  with  all  purely  manual  things  a  knowledge  how  to  do  them  is  mere- 
ly a  start.  It  requires  prolonged  practice  to  be  able  to  do  them  well. 
An  orchestra  leader  knows  how  the  instruments  should  be  played,  yet  is. 
unable  to  play  upon  any  except  the  one  on  which  he  has  spent  a  lifetime 
of  practice.  Were  it  not  for  the  evidence  of  the  performance  of  others, 
a  beginner's  first  instrumental  musical  attempt  would  lead  him  to  think 
impossible  many  of  the  manual  things  that  later  are  as  easy  to  him  as 
walking.  Other  and  new  difficulties  will  arise  and  will  be  overcome ; 
there  will  always  be  difficulties  worthy  of  continual  practice  in  order  to 
acquire  the  utmost  tactile  and  co-ordinate  dexterity.  So  it  is  with  peroral 
endoscopy.  Herbert  Tilley  (Bib.  545)  very  aptly  states  that,  "While  it 
would  be  idle  affectation  to  suggest  that  neither  skill  nor  practice  is  ne- 
cessary for  the  intelligent  use  of  the  bronchoscope,  yet  it  is  very  true 
that  a  little  practice  combined  with  patience  and  gentleness  should  ren- 
der any  surgeon  comiictent  to  use  the  bronchoscope  with  reasonable  as- 
surance." W  hile  the  author  believes  that  more  than  a  little  practice  is 
desirable,  he  heartily  concurs  in  the  foregoing  statement  because  of  the 
qualifying  clause  "'combined  with  patience  and  gentleness."  These  are 
the  great  safeguards  of  endoscopy. 

As  with  instrumental  music  certain  personal  qualifications  will  en- 
able better  endoscopic  work  and  especially  is  this  true  in  diflicult  foreign- 
body  cases.  Good  eyesight  without  excessive  refractive  errors  comes 
first  in  imjiortance.  Endless  patience  is  an  essential.  A  good  faculty  of 
orientation  will  stand  the  endoscopist  in  good  stead.  Mechanical  in- 
genuity is  necessary.  The  greatest  percentage  of  successes  will  accrue 
to  him  who  is  so  constituted  as  to  work  calmly  and  deliberately,  yet 
quickly  and  accurately,  under  severe  stress  of  ])rolonged  work  with  one 
eye,  subject  to  great  anxieties  and  where  a  mistake  or  lack  of  prompt- 
ness and  accuracy  may  mean  the  flcath  of  the  ])aticnt  either  immediately 
or  by  default  ultimately.  There  is  absolutely  nothing  like  it  in  the  whole 
realm  of  surgery.     The  operator's  ordeal  is  well  described  by  Ingals  as 


200  ACgilRING   SKILL. 

folluws:  "'riie  heart-breaking  delays,  the  extreme  anxiety  for  the  pa- 
tient and  the  knowledge  that  jjrolonged  operations  of  this  kind  are  dan- 
gerons,  while  failure  may  spell  death  for  the  patient,  place  the  operator 
under  such  circumstances  under  an  indescribable  stress.'' 

The  greatest  difficulty  will  be  encountered  by  the  surgeon  who  has 
been  accustomed  always  to  work  with  both  hands  and  both  eyes  in  an 
open  wound.  Such  a  one  will  tind  difficulties  in  working  with  the  mirror 
in  ordinary  indirect  rhino-laryngologic  work,  and  endoscopy  will  ])re- 
sent  to  him  difficulties  infinitely  greater.  Far  be  it  from  the  author  to 
deter  any  one  from  taking  up  bronchoscopy  and  esophagoscopy.  On  the 
contrary,  it  has  been  the  author's  endeavor  for  years  to  popularize  these 
procedures  with  the  jirofession  and  to  induce  every  one  who  is  willing 
to  devote  to  it  the  necessary  amount  of  practice,  to  take  it  up.  In  fact 
it  is  because  the  author  once  said  that  bronchoscopy  and  esophagoscopy 
were  easy,  that  he  deems  it  at  this  late  day  necessary  to  issue  a  word 
of  caution  against  taking  up  the  work,  especially  in  foreign  body  cases, 
without  due  appreciation  of  the  difficulties  to  be  met  and  overcome  only 
by  continual  practice. 

The  foregoing,  however,  applies  only  to  foreign  body  work,  direct 
lan'ngeal  operating,  and  a  few  other  procedures  like  the  dilatation  of 
bronchial  and  esophageal  strictures,  exploration  of  the  subdiverticular 
esophagus,  and  the  like.  It  does  not  apply  to  the  exposure  of  the  larynx 
for  diagnosis  or  for  the  introduction  of  intratracheal  insufflation  tubes, 
which  procedures  anyone  can  easily  learn  without  special  forehead  mir- 
ror experience  or  special  qualifications.  The  author  believes  that  every 
laryngologist  of  the  future  will  be  considered  incompetent  if  he  cannot 
examine  the  larynx  of  any  child  by  direct  laryngoscopy,  and  that  the 
rhino-laryiigologist  (who  of  necessity  is  trained  by  years  of  work  with 
one  eye  through  narrow  o])enings  )  is,  logically,  the  best  man  fitted  for 
bronchoscopy  and  esophagoscopy,  and  he  should  be  a  bronchoscopist  and 
an  esophagoscopist.  If,  however,  the  laryngologist  prefers  not  to  de- 
vote the  time  and  attention  needed  to  do  them  well,  he  may  refer  cases 
requiring  bronchoscopy  and  esophagoscopy  to  some  near  neighbor  who 
is  equipped:  but  escape  direct  laryngoscopy  he  cannot,  if  he  desires  to 
be  called  a  laryngologist.*  It  is  the  author's  hope  and  belief  that  per- 
fection in  direct  laryngoscopy  will  lead  every  rhino-larjngologist  pos- 
sessed of  good  eyesight  to  be  also  a  broncho-esophagoscopist.  For 
foreign-bodv  work  a  large  instrumental  outfit  is  necessary,  but  no  arma- 
mentarium, however  complete,  will  lessen  the  need  for  prolonged  co- 
ordinate education  of  the  eye  and  the  fingers.  To  some  extent,  this 
might  be  said  of  surgeiy  in  general ;  but  with  endoscopy  it  will  be  very 
different  if  none  of  the  ])revious  training  of  the  surgeon  has  been  in  the 

•Extracted  frum  the  -Vuthor'.s  "l!a|)i)ui  t"  at  tlu-  International  Medical  C'on- 
eress,    London.    1913. 


AforiKINC.    SKIM..  201 

line  of  working  with  one  eye  while  ij,nioriny  the  image  of  the  other,  nor 
in  the  jiracticc  of  depth  jierception  with  one  eye  only.  Estimation  of 
distances  is  under  all  circumstances  largely  a  matter  of  personal  e(|ua- 
tion,  some  persons  being  remarkably  adept  naturally,  wdiile  others  find 
it  exceedingly  difficult  to  make  even  an  approximate  estimate  of  so  ap- 
parent a  distance  as  the  width  of  a  street.  Such  difficulties  in  making 
estimates  are,  of  course,  enormously  increased  when  they  are  to  be 
made  with  one  eye  only  and  looking  through  a  tube.  Much  practice, 
howe\er,  will  enable  anyone  to  estimate  with  sutTicient  accuracy  the  va- 
rious depths  of  the  tissues  seen  in  the  endoscopic  image;  and  those  with 
natural  aptitude  can  develop  this  depth  perception  to  an  extent  that 
seems  incredible.  -Much  as  it  may  hurt  the  self-esteem  of  the  surgeon, 
after  his  years  of  exjjerience  in  surgery,  if  he  wishes  to  do  bronchoscopy 
for  foreign  bodies,  he  must  begin  at  the  beginning  and  take  endless  hours 
of  practice  on  the  dog,  unless  he  be  so  heartless  as  to  do  his  first  tube 
work  on  human  beings.  Practice  on  human  beings  in  the  general  field 
of  surgery  is  very  different,  because  the  careful  man,  working  in  an  ojien 
wound  with  both  eyes  and  both  hands,  and  with  an  experienced  surgeon 
assisting,  will  do  no  harm.  The  very  worst  that  may  follow  is  siinply  a 
prolongation  of  the  operation.  In  endoscopy,  prolongation  is  often  a 
very  serious  matter ;  and  the  errors  of  omission  and  those  of  commission 
may  be  fatal  both  by  default  in  not  removing  the  foreign  body ;  in  mak- 
ing it  im])ossible  for  anybody  else  to  remove  it ;  or  in  producing  fatal 
trauma  or  respiratory  arrest.  Master  and  pupil  cannot  see  at  the  same 
time  in  endoscopy. 

Fur  the  acquirement  of  skill  five  modes  of  education  of  the  eye  and 
fingers  are  available. 

1.  I'reliminary  practice  with  bronchoscope  and  forceps. 

2.  I'ractice  upon  the  cadaver. 
'.].     I'ractice  upon  the  dog. 

•1,     .Sketching  the  endoscopic  image. 

5.     I'ractice  upon  human  beings. 

Prcliininary  practice.  The  first  step  for  the  beginner  in  endoscopy 
should  be  the  mastery  of  the  mechanical  details  of  tubes  and  their  illumi- 
nation. He  should  learn  just  the  degree  of  illumination  the  lamps  will 
stand  without  burning  them  out  or  shortening  their  "life."  Carbon  fila- 
ment lanijis  will  stand  only  an  am])erage  that  is  indicated  by  the  filament 
hct/iiiiiiiK/  to  turn  white.  Tungsten  filament  lamps  illuminate  with  a  less 
amperage,  but  the  rheostat  may  be  run  up  until  the  filament  gets  (|uite 
white.  Tf  after  an  hour's  use  the  glass  of  the  lamp  shows  black  it  in- 
dicates that  the  lamp  has  been  overilluminated.  Some  instruction  by  an 
electrician  is  valuable.  These  .suggestions  apply  to  all  forms  of  instru- 
ments.    With   the   I'.ninings  and    Kahler  instruments  the  adjustment   of 


202  ACQUIRING  SKILL. 

illumination,  centering  of  the  light,  etc.,  should  always  be  done  as  a  pre- 
liminary ;  not  while  the  tube  is  in  the  patient.  With  the  author's  instru- 
ments if  it  is  desired  to  inspect  the  lamp  while  the  endoscopic  tube  is 
in  the  patient,  the  light  carrier  may  be  withdrawn  and  the  lamp  replaced 
or  adjusted.  With  any  form  of  instrument  it  is  a  mistake  to  turn  on 
more  current  with  the  tube  in  the  patient  every  time  the  field  seems  in- 
sufficiently illuminated.  The  loss  of  light  may  be  due  to  soiling  or  mois- 
ture condensation  on  the  mirror  of  handlamps  or  headlamps,  to  secretion 
in  the  tubes,  etc.  With  the  Briinings  instrument  the  manipulation  of  the 
reflector  should  be  practiced  so  that  the  light  may  be  cjuickly  centered. 
This  is  accomplished  by  adjusting  the  mirror  so  that  the  crossing  point 
of  the  filaments  in  the  image  projected  onto  any  vertical  plane  is  seen 
to  be  exactly  concentric  with  the  center  of  the  tube  through  which  the 
observer  is  looking.  The  swinging  aside  of  the  mirror  carrier  should  be 
practiced  because  this  must  be  promptly  done  in  anticipation  of  the  pa- 
tient's every  cough  to  prevent  soiling  of  the  mirror.  Practice  in  the 
left-handed  insertion  of  the  inner  tube,  and  in  looking  through  the  mir- 
ror slot  is  essential  to  good  work.  All  of  the  instrumental  manipulations 
above  referred  to  can  be  as  well  learned  on  inanimate  objects  an  on  a 
patient.  The  Kirstein  headlamp  as  used  by  Killian,  and  the  Claar 
headlight  as  used  by  Guisez  re(|uire  focusing  and  adjustment  to  insure 
parallelism  between  the  visual  and  illuminant  axes,  which  will  not  be 
difficult  for  the  laryngologist.  who,  of  course,  is  accustomed  to  work  with 
head  mirrors  and  headlights.  The  Kirstein  and  Claar  headlights  may, 
indeed,  be  used  with  great  advantage  in  nasal  and  indirect  laryngeal 
work.  The  next  step  is  preliminary  practice  with  bronchoscope  and 
forceps  in  picking  up  threads  from  a  table.  The  small  bronchoscope 
(.J  mm.)  should  be  used  and  the  forceps  should  never  be  closed  except 
under  guidance  of  the  eye  at  the  proximal  tube-mouth.  First,  short  bits 
of  black  threads  on  a  white  cloth  should  be  used :  then  white  threads  on 
a  white  cloth,  finally  black  threads  on  a  black  cloth.  Incidentally  it  may 
be  mentioned  that  this  thread  practice  is  an  excellent  method  of  testing 
the  different  form  of  instruments  and  illumination  in  order  to  select  the 
kind  best  suited  to  the  operator's  personal  ecjualion.  Comparisons  should 
be  with  tubes  of  equal  diameters. 

The  conscientious  beginner  will  engage  in  preliminary  practice  un- 
til all  of  the  manipulations  are  automatic. 

Practice  on  the  cadaz'er  is  very  useful  for  the  study  of  tlie  local 
anatomy  because  there  are  no  reflexes  or  secretions  to  hinder.  Anyone 
can  fumble  around  until  he  succeeds  in  exposing  the  cadaveric  larynx 
and  introducing  the  bronchoscope  or  esophagoscope ;  but  this  is  not  the 
best  method  of  study.  The  influence  of  position  should  be  carefully 
noted  by  lowering  the  head  to  the  Rose  position.     Then  the  direct  laryngo- 


ACQUIRING  SKILL.  203 

scope  should  be  introduced  and  the  fully  extended  head  gradually  raised 
until  the  vertex  is  higher  than  the  table.  The  laryngeal  exposure  ob- 
tained will  give  the  key  to  the  proper  position  for  peroral  endoscopy. 
Then  the  bronchoscopic  and  esophagoscopic  anatomy  should  be  studied. 
Particular  attention  should  be  given  to  appreciation  of  distances  especial- 
ly those  from  the  glottis  to  the  bifurcation ;  from  the  bifurcation  to  the 
upper  lobe  bronchi  on  the  right  and  the  left  sides  respectively ;  and  from 
the  right  upper-lobe  bronchus  to  the  middle-lobe  bronchus.  The  angle  of 
branching  of  the  larger  bronchi  is  also  important,  though  these  angles  are 
apt  to  be  distorted  in  the  cadaver.  The  beginner  in  endoscopy  should  make 
himself  familiar  with  all  parts  of  the  tracheo-bronchial  tree  so  that  he 
knows  instinctively  how  to  reach  any  desired  location.  All  of  these 
things  can  be  learned  quicker  and  better  on  the  cadaver  than  on  the 
living  and  they  cannot  be  learned  at  all  from  books. 

Practice  upon  the  dog.  The  next  step  in  the  endoscopist's  training 
should  be  the  education  of  the  eye  to  the  prompt  comprehension  of  the 
endoscopic  pictures  by  practice  upon  the  dog.  This  will  be  of  little  use 
so  far  as  the  exposure  of  the  larynx  and  the  introduction  of  the  broncho- 
scope and  esophagoscope  in  the  human  being  are  concerned,  because 
the  dog  does  not  jM-esent  the  difficulties  arising  in  the  human  being  from 
the  right-angled  pharyngeal  turn  of  the  air  and  food  passages.  Never- 
thelesS;  practice  on  the  dog  is  of  the  utmost  importance  in  training  the  eye 
and  the  fingers.  The  mentality  of  vision  must  be  educated  not  only  to 
comjjrehend  the  endoscopic  image  but  it  must  comprehend  the  ever  chang- 
ing image  jiromptly.  The  histologist  must  educate  his  eye  to  extreme 
niceties  of  morphologic  distinctions,  but  he  has  no  end  of  time  in  which 
to  study  each  field.  The  endoscopist  in  making  observations  in  the  air 
and  food  passages  must  observe  not  only  form  but  color;  and  most  ditti- 
cult  of  all.  his  object  is  never  still  a  moment,  never  twice  in  precisely  the 
same  position. 

It  takes  much  practice  to  be  sure  when  the  forceps  are  at  the  proper 
depth  to  grasp  the  foreign  body  or  particular  piece  of  tissue.  Dog  work 
is  better  than  cadaver  work  for  practice  in  this  direction,  because  the 
colors,  and  especially  the  constant  respiratory,  ])ulsatory,  bechic,  and, 
in  case  of  the  esophagus,  peristaltic  and  antiperistaltic  movements  present 
actual  working  conditions.  Xo  one  should  think  of  attempting  for 
the  first  time  to  remove  a  foreign  body  from  a  human  being  until  he  has 
at  least  H>0  times  removed  a  foreign  body  from  a  dog.  If  the  operator 
has  jjul  little  endoscopic  work  to  do,  he  should  practice  between  times  on 
the  dog  in  order  to  maintain  skill.  In  foreign  body  practice  on  the  dog, 
it  is  well  to  remember  that  this  animal  is  peculiarly  well  able  to  rid  him- 
self of  foreign  bodies.  He  can  get  open  safety-pins  and  sometimes  even 
fish-hooks  out  of  his  bronchi.     .Manv  letters  of  chagrin  have  come  to  the 


204  ACQUIRING   SKILL. 

author  relating  inability  to  find  foreign  bodies  introduced  a  day  or  two 
before.  If  for  any  experimental  purpose  it  is  desired  to  have  a  foreign 
body  remain  in  the  canine  lower  air  passages,  it  is  necessary  to  devise  a 
very  secure  anchorage.  A  small  dog  is  preferable.  Large  dogs  require 
longer  instruments  than  human  beings.  Scopolomine  0.00065  gm.  with 
morphine  0.0324  gm.  hypodermatically  is  a  convenient  anesthetic  for  a 
small  dog.  It  should  be  given  an  hour  in  advance  and  repeated,  if  neces- 
sary. 

Sketching  the  endoscopic  image.  One  of  the  best  ways  to  educate 
the  eye  to  grasp  (juickly  the  fleeting  panoramic  endoscopic  views  is  to 
practice  sketching.  However  crude,  artistically,  the  effort  may  be,  the 
practice  of  quickly  observing  form  and  color  of  the  visible  field  will  be 
of  inestimable  value.  Practice  catching  the  darks  first  and  jot  them 
down  with  pencil  in  previously  scribed  circles.  After  the  habit  of  quick- 
ly noting  the  darks  is  formed,  the  noting  of  the  lights  as  to  their  form 
is  easily  ac(|uired.  for  m  a  measure,  the  lights  take  care  of  themseKes 
because  they  are  necessarily  blocked  out  by  the  darks.  The  noting  of 
the  color  comes  next.  The  color  of  the  darks  is  unimportant  for  train- 
ing of  the  eye.  though,  of  course,  very  necessary  for  accurate  illustra- 
tion. For  the  recognition  of  disease  it  is  necessarv  to  observe  the  color 
of  the  well-illuminated  parts — the  lights.  If  the  sketching  method  of 
educating  the  eye  as  here  outlined  is  practiced,  it  is  remarkable  how  the 
eye  will  acquire  the  habit  of  quickly  recording  successive  pictures  of 
form  and  color.  .\s  the  field  of  view  is  small  the  form  and  position  of 
the  darks  and  the  color  of  the  lights  are  taken  in  over  different  parts  of 
tiie  whole  field  simultaneously.  If  desired,  pencil  and  sketch  cards  with 
scribed  circles  can  be  sterilized  in  alcohol  for  use  on  the  instrument  table, 
but  it  is  scarcely  justifiable  to  keep  a  patient  endoscoped  either  with  or 
without  an  anesthetic.  Moreover,  it  is  quite  unnecessary,  because,  if  the 
essential  amount  of  endoscopic  practice  on  the  dog  is  done,  the  sketch- 
ing can  be  there  practiced  until  not  only  will  the  education  of  the  eye 
be  perfected,  but  the  mental  habit  of  recording  impressions  will  be  ac- 
quired, so  that  a  series  of  a  half  dozen  or  more  pictures  can  be  sketched 
from  memory  immediately  after  the  endoscopy  is  finished.  Unless  one 
has  had  much  previous  training  in  water  or  oil  colors,  wax  crayon  pen- 
cils are  best,  as  thev  do  not  require  a  fixative  like  pastels,  though  their 
tints  are  not  quite  so  accurate  or  so  easily  blended  or  overworked.  Faber 
makes  (iO  dift'erent  tints  under  the  name  of  "Castex  Polychrome"  pencils. 
Numbers  31,  34,  30,  'M .  in  and  -"i".;  will  probably  be  found  most  useful. 
P.lending  can  be  done  with  a  clean,  pointed  pencil-eraser.  So  far,  no 
]ihotographic  method  of  recording  endoscopic  views  of  the  air  and  food 
passages  has  yielded  very  satisfactory  results,  not  only  because  of  the 
feebleness  and  reddish  tint  of  the  return  ravs,  but  mainlv  l)ecause  of  the 


ACQUIRING   SKlI.l,.  205 

perpetual  mo\cnieiU  which  prevents  lengthy  exposure.  L'ntil  some  diffi- 
cult problems  are  overcome,  jjencil,  crayon  and  brush  are  the  only  means 
of  recording  a])pearances. 

Practice  upon  hujiian  bciHi/s.  It  is  stated  above  that  dog  and  cada- 
ver i)ractice  do  not  help  greath-  in  overcoming  the  difficulties  of  introduc- 
tion. Dog  and  cadaver  practice  do  help  to  some  extent,  because  the 
education  of  the  eye  promptly  to  appreciate  the  endoscopic  image  is 
fundamental :  but  the  knack  of  displacement  for  laryngeal  exposure  and 
of  passing  the  cricopharyngeus,  esophagoscopically.  are  yet  to  be  learned 
and  for  these  purposes  only  the  human  being  will  serve.  L'ntil  human 
direct  laryngoscopy  is  learned  no  attempt  should  be  made  to  do  bron- 
choscopy or  esophagoscopy.  Respirator}'  arrest  during  the  progress  of 
esophagoscopy,  or  after  the  withdrawal  of  the  bronchoscope  in  bronchos- 
copy, demands  that  for  the  safetv  of  the  patient  the  operator  shall  be 
able  promptly  to  expose  the  laryn.x  and  insert  the  bronchoscope  for 
oxygen  insufflation.  The  familiarity  with  the  location  of  the  pyriform 
sinuses  and  laryngopharynx  under  direct  view  is  (|uite  essential  to  esoph- 
agoscopy. To  anyone  who  is  skillful  at  cx])osing  the  larynx,  the  intro- 
duction of  the  bronchoscope  is  easy,  and  no  one  should  attemj)!  bron- 
choscopy until  he  has  acquired  sufficient  skill  to  expose  the  larynx  in 
almost  any  patient  in  15  seconds.  Seldom  should  it  require  more  than  8 
seconds.  One  ought  to  be  able  to  hold  the  laryn.x  in  view  long  enough 
for  half  a  dozen  men  to  take  a  look.  Fortunately  there  is.  in  all  out- 
jiatient  clinics,  a  goodly  percentage  of  cases  that  justify  direct  laryngos- 
copy. Any  patient  with  laryngeal  paralysis  of  undetermined  etiology 
or  any  patient  with  infiltration  of  the  arytenoid  re.gion  should  be  ex- 
amined for  disease  of  the  [larty  wall,  antcriorlw  and  also  down  in  the 
hypopharvnx.  Certain  cases  of  laryngeal  tuberculosis  are  benefited  by 
the  direct  application  of  the  galvano-cautcry.  ( )ther  material  that  can 
lie  conscientiously  used  will  readih-  be  fciiind,  because  direct  laryngos- 
copy in  any  case  not  dyspneic.  and  done  under  aseptic  precautions  is 
harmless.  Tracheotomized  cases  should  be  regularly  and  carcfullv  tra- 
cheoscoped  for  exuberant  granulations  which  may  occlude  the  lube  antl 
cause  death.  I'j-osions,  necrosis  of  cartilage,  edematous  areas  et  cetera, 
due  to  ill-titting  cannulae  are  remediable.  .\  plan  for  cure  of  the  stenosis 
can  only  in  this  way  be  formulated.  Such  cases  should  be  examined  from 
above  and  below.  Having  mastered  hy]i()])haryngoscopic  and  direct 
laryngeal  left-hand  exiJosure  in  the  human  being,  the  student  who  has 
followed  the  course  here  laid  out  need  have  no  hesitation  whatever  in 
attempting  bronchoscopy  or  esophagoscopy  in  any  case  where  these  pro- 
cedures are  not  contraiiulicated.  The  tirst  few  esophagoscopies  should 
be  emaciatcfl  adults  with  few  teeth,  and,  if  justifiable,  should  be  general- 
Iv  anesthetized. 


CHAPTER    XII. 

Foreign  Bodies  in  the  Air  and  Food  Passages. 

List  of  foreign  bodies  found  in  air  and  food  passages.  It  seems  to 
die  author  a  sacrifice  of  space  to  list  all  of  the  foreign  bodies  so  far 
found  in  these  passages,  since  any  substance  not  too  large  and  not  soluble 
may  be  encountered  endoscopically :  be  that  substance  from  the  animal, 
vegetable  or  mineral  kingdoms,  or  manufactured  therefrom  by  man. 
Rather  would  it  seem  profitable  to  classify  these  substances  by  the  me- 
chanical problems  of  their  extraction  and  this  will  be  done  in  future 
chapters.  It  may  be  well  here  to  classify  the  sources  of  foreign  bodies. 
The  following  classification  of  Voelcker,  quoted  by  Sir  St.  Clair  Thom- 
son, (Bib.  539)  is  comprehensive. 

1.  From  the  mouth — articles  of  food,  bones  of  meat  or  fish,  fruit 
stones,  peas,  beans,  shells,  seeds,  ears  of  corn,  grasses,  pieces  of  wood 
or  coal,  coins,  buttons,  pencils,  marbles,  toys,  broken  ]Mpe-stems,  pins, 
needles,  nails,  tooth-plates,  leeches. 

2.  From  the  stomach — vomited  food  or  blood,  or  the  migration  of 
lumbrici  or  threadworms. 

3.  From  the  lungs — hemoptysis,  hydatids. 

4.  From  the  outside — as  by  penetration  of  a  pin,  dart,  bullet,  or 
drainage-tube  from  the  neck. 

5.  From  surgical  measures — detached  portions  of  instruments, 
sprays,  brushes,  cotton-wool,  gauze,  sponges,  ;mlrum  plugs,  intubation 
tubes,  broken-of¥  cannulae  of  tracheotomy  tubes,  amputated  tonsils,  ade- 
noids or  other  growths  and  hemorrhage. 

6.  Arising  in  situ — necrosed  cartilage,  ulcerating  sloughs,  mem- 
brane, effused  blood. 

7.  Penetration  from  the  neighborhood — ulceration  or  extension  of 
malignant  disease  from  the  pleura,  thyroid  gland,  or  esophagus,  or  the 
penetration  of  a  tuberculous  gland  from  the  mediastinum. 

To  this  list  might  be  added  the  penetration  of  a  foreign  body  from 
the  esophagus  into  the  trachea,  of  which  the  author  has  seen  two  in- 


FOREIGN  BODIES  IX   AIR  AND  1-OOD  PASSAGES  207 

Stances,  and  the  penetration  of  a  foreign  body  from  the  tracheo-bron- 
chial  tree  into  the  esophagus  of  which  the  author  has  seen  one  instance, 
that  of  a  sharp  fragment  of  bone  the  point  of  which  was  visible  in  the 
esophagus,  but  which  was  removed  liy  bronchoscopy  from  the  left  bron- 
chus. 

Prophylaxis.  Many  of  the  foreign-body  accidents  are  entirely  pre- 
ventable. If  no  one  put  into  his  mouth  anything  but  food,  foreign- 
body  cases  would  be  rare.  In  the  author's  collection  only  about  three 
per  cent  are  proper  articles  of  food  and  these  mostly  insufiliciently  mas- 
ticated or  cooked.  This  does  not  include  the  foods  removed  from  stric- 
tured  esophagus.  .\  much  larger  percentage  are  substances  normally  in 
food  stuffs  but  not  removed  before  eating,  such  as  bones,  shells,  hulls 
and  seeds.  More  care  in  the  preparation  of  food  and  in  the  eating  of 
fruits  with  large  seeds  is  of  first  prophylactic  importance.  Care  in  the 
preparation  of  foods  can  easily  prevent  the  accidental  presence  of  pins. 
needles,  bits  of  china  and  glass,  enamelling  and  solder  from  utensil's  and 
the  like.  Tradesmen,  such  as  lathers,  carpetmen  and  upholsterers  who 
carry  tacks  and  nails  in  their  mouths  could  just  as  easily  have  learned 
in  the  beginning  some  less  dangerous  as  w'ell  as  less  filthy  method,  and 
apprentices  should  be  so  taught.  Magazines  with  automatic  feeding 
mechanisms  could  easily  be  devised  that  would  also  save  time,  wdiich  latter 
feature  is  the  only  one  that  would  appeal  strongly  to  the  employer.  Chil- 
dren should  he  taught  from  infancy  not  to  put  anything  inedible  into  their 
mouths.  A  large  part  of  the  infantile  education  as  to  the  physical  na- 
ture of  the  portable  substances  in  reach  comes  from  testing  them  in  the 
mouth ;  but  this  natural  tendency  can  be  combated  as  can  also  the  in- 
fantile effort  to  assist  dentition  by  biting  on  various  substances.  How- 
ever, if  mothers  and  nurses  make  a  special  elTort  it  is  remarkable  how 
readilv  most  children  even  as  early  as  the  second  year  can  be  taught  by 
reproof.  Younger  children  must  be  watched.  The  frequency  with  which 
pins,  buttons  and  safety-pins  are  removcil  by  endoscopists  points  to  care- 
lessness in  leaving  these  things  within  the  liaby's  reach.  Teething  rings 
and  the  toys  of  children  should  all  be  too  large  to  get  beyond  the  mouth 
into  the  air  or  food  passages,  and  all  toys  should  be  regularly  inspected  for 
loose  parts  likely  to  become  detached.  Digital  efforts  at  removal  are 
frequently  res])onsil)le  for  dislodging  and  forcing  downward  foreign  bod- 
ies that  could  be  readily  removed  from  the  ])harynx  with  forceps.  The 
index  finger  curling  forward  hook-like  in  an  efiort  to  remove  an  object 
from  the  laryngo-pharyn.x  is  very  apt  to  force  the  object  into  the  larynx. 
Parents,  nurses,  dentists  and  physicians  should  bear  this  in  mind.  Nurses 
and  phvsicians  understaufl  fully  about  removing  artificial  dentures  from 
the  mouth  preparatory  to  anesthesia ;  but  they  are  not  so  often  alert  to 


208  FORKICN   BODIES  IN'  AIR  AND  1-OOD  PASSAGKS. 

the  same  potential  dangers  in  case  of  unconsciousness  from  alcoholic 
intoxication,  delirium,  syncope,  shock,  collapse  and  sleep,  especially  the 
dozing  or  nap  of  the  daytime. 

Foreign  bodies  in  the  hysteric  and  the  insane.  We  must  always  be 
on  our  guard  against  the  cases  which  come  in  with  the  most  positive  as- 
surance by  the  patient  that  there  is  a  foreign-body  present.  These  cases 
are  of  two  classes.  Those  who  have  had  a  foreign  body  which  has  passed 
on  downward  and  left  some  traumatism,  the  sensations  of  which  lead  the 
patient  to  believe  that  the  foreign  body  is  still  present,  and  the  hysteric 
patient  who  believes  she,  or  he  has  a  foreign  body.  In  regard  to  the 
hysteric  class,  it  is  a  great  mistake  to  do  a  bronchoscopy  with  the  ho])e 
of  cure  by  suggestion.  Such  "cures"  are  ephemeral.  The  foreign-body 
illusion  will  recur  with  more  and  more  persistence  and  amplification  the 
more  often  it  is  removed  by  suggestion.  .\s  is  well  known,  two  of  the 
most  prominent  characteristics  of  hysteria  are  the  hunger  for  sympathy 
and  the  desire  to  mystify  and  astonish  the  physician  by  unusual  simula- 
tions of  disease.  The  border  lines  between  pure  hysteria  and  the  hys- 
teriform  symptoms  of  paranoia  on  the  one  hand,  and  between  the  hys- 
teriform  and  the  suicidal  symptoms  of  paranoia  on  the  other  hand,  are 
too  abstruse  for  the  author.  These  matters  concern  the  psychiatrist.  The 
question  that  must  be  determined  by  the  endoscopist  is  wdiether  or  not 
to  do  an  endoscopy  and  if  so  whether  it  shall  be  first  a  bronchoscopy  or 
an  esophagoscopy  in  case  indirect  mirror  examination  prove  negati\e. 
In  case  of  foreign  body  visible  radiographically,  or  one  that  has  pro- 
duced a  visible  lesion  such  as  abscess,  the  (|uestion  is  ([uicklv  decided. 
In  all  other  cases  there  are  four  safe  rules  to  follow  : 

1.  Consider  only  objective  symptoms. 

2.  Consider  only  testimony  of  persons  other  lh:in  the  patient  as  tc 
history. 

3.  In  all  cases  of  doubt  make  a  thorough  endoscopic  search. 

4.  If  endoscopy  is  negative  do  not  worry  about  the  patient's  later 
assertion  that  she  coughed  up  the  foreign  body  that  you  failed  to  find. 
It  is  parallel  with  the  hysteric  crijjples  that  throw  away  their  crutches 
after  a  faith  cure. 

Remarkable  cases  of  nuilti|)le  foreign  bodies  in  the  stomach  of  the 
insane  are  not  uncommon.  A  certain  pro])ortion  of  these  are  almost 
certain  to  be  metallic,  or  of  lead,  glass  or  porcelain  and  dense  to  the  ray. 
Some  such  bodies  may  be  removed  wath  the  10  mm.  x  ."i^  cm.  esophago- 
gastrosco[)e.  .\s  a  rule,  however,  the  objects  that  appeal  to  the  insane 
are  of  a  kind  that  ajipears  most  appalling  to  them  such  as  open  pocket- 
knives,  shar])  glass  and  the  like.  These  are  best  remo\  ed  by  the  abdom- 
inal surgeon  by  external  operation.     Should  any  object,  of  whatever  kiiul. 


I-ORKIGX   I'.OniKS  IN   AIR  AND  FOOD  PASSAGES. 


209 


lodge  in  the  esophagus,  larynx  or  trachea,  however,  it  should  be  removed 
endoscopically,  and  it  should  not  he  pushed  down  into  the  stomach  as 
fatal  trauma  is  \ery  likely  to  result.  In  most  instances  it  will  he  in  the 
esophagus  that  the  endoscopist  will  be  required  for  foreign  body  work  in 
the  hysteric  and  the  insane.  The  author  has,  however,  had  one  case  of 
\()luntary  aspiration  of  a  foreign  liody  into  the  bronchi,  following  a 
probablv  accidental  similar  asiiiration. 


Fie.  154.  Racliograi)h  by  IJr.  Lewis  G.  Cole,  sliouiiii;  two  Uicl<s  in  ;i  posterior 
l)ranch  of  the  right  inferior  lobe  bronchus.  Tacks  removed  by  lironchoscopy 
through  the  mouth. 


A  cose  of  voluntary  aspiration  of  a  foreign  body  into  the  bronchi, 
removal  by  bronchoscopy.  At  the  Eye  and  Ear  Hospital,  of  Pittsburgh, 
the  author  removed  liy  bronchoscopy,  two  tacks  from  a  posterior  branch 
of  the  right  inferior  lobe  bronchus  of  a  woman  aged  forty-one  years,  re- 
ferred by  Dr.  J..  G.  Cole,  of  New  York  City,  who  made  the  excellent 
radiograph  (Fig.  1.54).     The  anesthetic  was  ether,  given  bv   Dr.   Homer 


210  FOREIGN  BODIES  IN  AIR  AND  FOOD  PASSAGES. 

McCready.  The  bronchi  were  so  full  of  pus  that  the  patient  nearly 
drowned  in  her  own  secretions.  After  the  bronchoscopic  removal  of  the 
pus  the  tacks  (Fig.  lo."))  were  removed  without  difficulty,  the  first  tack 
requiring  one  and  one-half  minutes  and  the  second  one  two  minutes,  as 
timed  by  ]\Iiss  Crock.  At  the  operation  the  author  had  the  kind  assist- 
ance of  Drs.  John  W.  Boyce,  Homer  McCready,  Jesse  Meyer  (St. 
Louis),  Richard  Lewisohn  (New  York).  Four  months  after  the  re- 
moval of  the  tacks,  as  reported  in  the  foregoing,  the  patient  came  to  Dr. 
Cole's  office  at  the  suggestion  of  Dr.  Geo.  \V.  Bogart,  stating  that  she 
had  the  same  old  symptoms,  and  she  thought  there  must  be  more  tacks 
there.  She  further  said  that  the  tacks  Dr.  Jackson  took  out  were  cor- 
roded, yet  the  last  one  just  coughed  up  was  bright  and  new.  A  radio- 
graph showed  one  tack  on  each  side  of  the  thorax.  Fig.  l."i(>,  not  so  near 
the  periphery  as  the  previous  tacks.  The  question  then  arose  how  could 
the  patient  get  the  tacks  into  the  bronchi  voluntarily,  as  it  was  clear  that 
she  was  a  hvsteric,  if  not  demented.     Dr.  John  \\".  Bovce,  in  consultation 


Fig.    155.     Tacks   removed   by   bronchoscopy    from   posterior   branch   of    right 
inferior  lobe  bronchus  of  a  woman  aged  41  years,  referred  by  Dr.  Lewis  G.  Cole. 

on  this  point,  said  that  by  throwing  a  number  of  tacks  into  the  pharynx 
and  taking  a  deep  inspiration,  she  might  get  one  or  two  down,  but  in  so 
doing  she  would  swallow  many  more  than  she  could  aspirate,  so  that,  if 
not  too  late,  a  radiograph  would  show  tacks  in  the  alimentary  canal  in 
progress  of  passing  through.  An  excellent  radiograph  by  Dr.  Cole  showed 
four  tacks  in  the  abdomen  (Fig.  1.57).  The  author  removed  the  tacks 
(Fig.  l.iS)  from  the  bronchi  in  the  French  Hos]iital  of  New  York  City 
with  the  kind  assistance  of  Drs.  Robert  C.  Myles,  J.  H.  Abraham,  John 
McCoy,  T.  Taylor  and  Geo.  \V.  Bogart,  the  head  being  held  in  the  Boyce 
position  by  Dr.  D.  T.  Sable  and  the  anesthetic  (  chloroform)  being  skill- 
fully administered  by  Dr.  T.  Drysdale  Buchanan.  There  was  a  most  in- 
tense inflammation  of  all  the  bronchial  mucosa  and  large  quantities  of  pus 
were  removed.  The  tack  in  a  posterior  branch  of  the  right  middle  lobe 
bronchus  was  readily  removed,  requiring  about  two  minutes,  but  the 
second  tack  in  the  posterior  branch  of  the  left  inferior  lobe  bronchus 
was  exceedingly  difficult  safely  to  remove.     It  was  imbedded  in  bleeding 


FORKIGX  BODII-.S  IX   AIR  AND  1"()0I)  I'ASS AGES. 


211 


granulation  tissue,  and  the  ])oint  had  perforated  the  opposite  wall  of  the 
next  larger  branch.  After  fifteen  minutes'  work  the  author  succeeded  in 
disengaging  the  point  and  renKiving  the  tack.  Two  radiographs  by  Dr. 
Cole  immediateU-  after  the  bronchoscopy  demonstrated  tliat  n(;  tacks  re- 
mained in  the  tliorax. 

Kemarks.     The  first  two  tacks  had.  no  doulil,  been  accidentally  as- 
pirated while  ])Utting  down  oilcloth  as  stated  by  the  ]iaticnt.     The  sym- 


FiG.  156.     Radiograpli  by  Dr.  L.  G.  Colo,  ul  tacks  \  >  iluntarily  aspirated  by  tlic 
patient. 


pathy,  the  interest,  the  seiisational  features  of  the  case,  and  the  anes- 
thetic evidently  appealed  to  the  neurotic  temjK'rament  of  the  patient, 
and  developed  the  hysteria  which  later  was  most  troublesomely  manifest 
in  ways  unnecessary  to  enumerate.  The  case  is  unique  in  that  it  has 
never  before  been  demonstrated  that  a  patient  could  vohnUarily  aspirate 
a  foreign  body  info  the  bronchi,  and  it  teaches  a  valuable  lesson  as  to 
how  to  detect  the  occurrence  by  radiography  of  the  abdomen  in  cases 
where  an  accident  is  denied.    In  all  hysteric  and  insane  patients  a  radio- 


212  FORKIGN  liOnTI'S  IN  AIR  AND  FOOD  PASSAGES. 

graph  slioiild  be  made  alter  removal  of  the  foreign  body  as  a  matter  of 
record. 

Procedure  in  a  case  of  suspected  foreign  body.  When  a  patient 
comes  complaining  of  a  foreign  body  in  the  air  or  food  passages  the 
(juestions  that  must  he  determined  are : 

1.      Is  there  a  foreign  body  present? 


Fig.  157.  Kacliuyraiih  li\  Dr.  L.  O.  CwL,  shuuiii.;;  Uicks  in  tlie  intestines  in 
progress  of  passing  through.  Tacks  were  swallowed  by  the  patient  in  attempt  to 
aspirate  them. 


2.  Where  is  it  located  ? 

3.  Is  a  peroral  endoscopic  i)rocedure  indicated? 

4.  Are  there  any  contraindications  to  endoscopy? 

o.  Shall  the  first  endoscopic  procedure  be  laryngoscopic.  broncho- 
scopic  or  csophagoscopic  ? 

The  questions  listed  above  are  so  interlaced  that  they  must  be  here 
considered  more  or  less  collectively  to  avoid  reiietition ;  but  to  determine 


l"OUi:ir..\  [;oDIi:S  IN  AIR  A\D  FOOD  PASSAGKS.  313 

these  (juesiious  (|uiekly  and,  so  far  as  possible,  accurately  requires  orderly 
investigative  procedures  as  applied  to  the  individual  case.  The  various 
steps  as  pursued  in  the  autlior's  clinic  arc  detailed  below,  in  the  order 
given.  ( )f  course,  if  the  foreign  body  is  located  in  the  earlier  stcjis  the 
investigation  may  terminate  at  any  stage. 

1.  History. 

2.  Indirect  examination  of  the  larynx;  then  the  naso-pharynx,  then 
the  tonsils  or  their  neighborhood. 

3.  Radiography. 

4.  Physical  examination  locally  in  the  neck  and  tli(jracically  as  well 
as  generally  by  an  internist. 

5.  Endoscop)'. 

History  of  the  patient  and  deductions  therefrom.  Carefully  taken 
histories  are  valuable  statistically  and  for  determining  the  question  of 
the  presence  ami  the  localization  of  a  foreign  body.  To  be  of  value 
statistically  it  is  necessary  that  a  blank  should  be  filled  out  in  order  that 
a  record  of  certain  details  shall  not  be  lacking  in  any  of  the  histories. 


il 


Flc.   158.     Tacks  voluntarily  aspirated.     Removi.-il  liy  lironclmscoiiy  ihroujili   thf 
mouth.     Covcrcil   with   dricil   lilooil   ;iik1   secretions. 


The  aiUhor  has  used  a  blank  of  which  l'"ig.  \M  is  a  reduced  illuslratinn. 
Ahnost  all  cases  come  in  with  a  history  of  having  "swallowed"  the  for- 
eign body,  and  we  must  be  on  our  guard  not  to  accept  this  as  meaning 
that  the  foreign  body  is  probably  in  the  esophagus.  As  many  of  the 
cases  iuNoKc  the  (|uesti<)u  of  ;i  foreign  body  not  opaqtie  to  the  ray,  we 
must  depend  up(jn  other  things  for  localization.  First  in  importance,  is 
to  lind  out  the  sxniptoms  at  the  time  the  foreign-body  accident  occurred, 
anil  ])arlicidarl\  ;is  to  whether  or  not  there  was  cough  or  ilyspnca  at  the 
time,  followed  with  blood  stained  expectin-ation,  because  very  often  alter 
a  short  period,  the  tolerance  of  the  air  passages  manifests  itself  in  a  total 
absence  of  symptoms.  It  is  very  rare.  howe\er,  that  there  is  no  cough- 
ing at  the  time  the  foreign  body  entered;  so  that  a  total  absence  of 
coughing,  pro\ided  some  one  is  at  hand  whose  observation  is  reliable, 
strongly  negatives  the  possibility  of  the  foreign  body  having  eiUerc<l  the 
trachea  or  larynx.  This,  of  course,  does  not  ajiply  to  ])atients  under  an- 
esthesia, to  the  intoxicated,  nor  to  anv  case  in  which  a  calm,  reliable  oli 


214 


FOREIGN  BODIES  IN  AIR  AND  FOOD  PASSAGES. 


CASE 
Name 

Address 

R^Si 

Referred  by 

History  taken  by 

Diagnosis 

Hospital 

Admitted 
Discharged 

Oq  admission 

General  health 


Age  Date 

Sex S..M,W.. 

..Owypptwu 


-N^tJyitj.. 


Private  case  or  ward  case. 


Nature  of  foreign  body 

How  long  was  the  foreign  body  in  air  passage  or  esophagus^ 

Immediate  sj79p_tpms_prqduccd_by_fo_r_eign  .body 

Symptoms  following  entrance  of  the  foreign  body 

Attempts  made  to  remove  it  before  direct  examination 

Pulmonary  symjjtoms 

Esophageal  symptoms 

Other  symptoms 

Result  of  X  Ray  examination 

Kind  of  method  employed  for  direct  examination 

J.  .^.■. . .  ^,*:^l- 


Anesthesia    b.    General. 

\  c.     No  Anesthesia. 
Operative  difficulties 
Instrument  em;>loye_d 


Resulting  instrumental  lesion 

Post-operative  pulmonary  and  esophageal  condition 

Operation  of  particular  interest 

Duration  of  convalescence 

Treatment 

Result  obtained 

Autopsy 

Bibhography 

Surgeon-in-chief 

Anesthetist 

Msistants 


Fig.  159.  History  sheet  for  foreign  body  cases.  After  the  foreign  body  has 
been  removed,  its  location  is  entered  on  the  top  hne  thus:  "Case.  Pin  removed 
bronchoscopically   from  dorsal  branch  of  right  inferior  lobe  bronchus." 


FOREIGN  BODIICS  IN  AIR  AND  FOOD  PASSAGES.  815 

server  was  not  present.  The  period  of  quiescence  during  which  there 
are  no  symptoms,  may  last  from  a  few  weeks  to  a  few  months  before  the 
symptoms  of  chronic  inflammatory  conditions  and  irritations  become 
manifest.  The  reverse  of  this  is  not,  however,  so  generally  applicable; 
because  after  some  preliminary  irritation  in  the  region  of  the  larynx  ex- 
citing cough,  the  patient  may  have  swallowed  the  foreign  body,  and  it 
may  have  lodged  in  the  esophagus.  Then  again,  there  may  be  severe 
dys]jnea  at  the  time  either  from  the  foreign  body  obstructing  the  larynx 
or  from  pressure  on  the  esophagus  below  the  cricoid  where  the  party- 
wall  is  membranous.  In  one  of  the  author's  cases,  a  surgeon  had  done  a 
tracheotomy  for  the  removal  of  a  foreign  body  supposed  to  be  in  the 
trachea  because  of  great  dyspnea.  Xol  finding  the  foreign  body  In  the 
trachea,  the  surgeon  asked  the  author  to  pass  a  bronchoscope.  On 
bronchoscopy,  through  the  mouth,  the  author  found  nothing  in  the  trachea 
or  bronchi.  Ksophagosco[))-,  however,  enabled  us  to  find  and  remove  the 
foreign  body  (a  coin  above  which  meat  and  other  food  had  become  im- 
pacted) in  the  upper  third  of  the  esophagus.  The  tracheotomy  was  per- 
fectly justifiable  and  lifesaving  because  it  was  done  for  dyspnea,  which 
was  relieved  completely ;  but  it  points  a  valuable  lesson  in  regard  to  the 
dyspnea  produced  by  esophageally  lodged  foreign  bodies.  Intermittent 
dyspnea  or  intermittent  cyanosis  after  a  history  of  choking  on  a  foreign 
body  is  practically  diagnostic  of  a  foreign  body  in  the  air  passages.  It 
is  most  apt  to  occur  in  flat  foreign  bodies,  which  allow  free  passage  of 
air  when  their  greatest  ])l;ine  corresponds  to  the  long  axis  of  the  air 
passages,  but  which  are  inure  or  less  obstructive  when  they  turn  side- 
wise.  This  may  occur  when  the  foreign  body  simply  rotates  in  a  semi- 
fixed position.  When  the  foreign  body  is  free  to  move  and  is  being 
coughed  up  against  the  under  surface  of  the  glottis,  there  is,  in  some 
cases,  a  very  decided  sudden  stoppage  of  the  glottic  space  by  the  bulk  oF 
the  foreign  body,  probably  plus  more  or  less  spasm  which  makes  a  very 
characteristic  sound  that  can  be  heard  some  distance  from  the  ])atienl. 
Tlie  intiTinittint  ilvspnea.  in  such  a  case,  may  occur  not  from  a  rocking 
val\e-like  action,  biU  sini]ily  the  intermittent  occlusion  of  tlie  subglottic 
trachea.  .\  remarkalile  dilterence  ijetween  foreign  bodies  in  the  trachea 
and  Ijronchi  as  com])ared  witli  a  similar  condition  in  the  esophagus  is 
that  foreign  bodies  which  are  too  small  to  cause  dyspnea  usually  cause 
the  patient  no  inconvenience.  I'",ven  cough  may  be  practically  absent,  so 
that  the  i)atient  is  almost  free  from  symptoms.  In  the  esophagus,  on  the 
contrary,  the  ]>;ilient  usually  feels  the  foreign  body  every  time  he  at- 
temijts  to  swallow,  and  there  is  usually  a  constant  sensation  of  distress 
and  annoyance.  Foreign  bodies  wliich  have  entered  the  air  passages  usual- 
ly cause  coughing  and  a  sense  of  suli'ocation  at  the  moment  that  the  for- 


216  FORKICN   P.OniK?  I\   AIR  AND  FOOD  PASSAGICS. 

eign  body  enters  the  trachea  :  but  thereafter,  there  is  no  sensation  of 
sufifocation  unless  the  foreign  body  is  very  large,  and  there  is  usually  no 
other  sensation.  When  an  intruder  enters  the  esophagus,  on  the  other 
hand,  there  is  usually  a  sensation  of  something  lodged  in  the  throat  and 
the  patient  is  impelled  to  make  repeated  swallowing  efforts  in  the  at- 
tempt to  dislodge  it.  Food  may  be  regurgitated  for  a  time  and  then 
swallowing  may  seem  normal,  leading  to  the  error  of  supposing  the  in- 
truder has  gone  down.  This  may  be  due  to  the  relaxation  of  the  spasm 
at  first  excited  by  the  presence  of  the  intruder,  or  it  may  be  due  to  the 
foreign  body  having  turned  to  a  less  obstructive  position.  Ingals  re- 
ports a  case  in  which  small  particles  of  corroded  iron  were  coughed  up 
from  a  nail  which  had  been  in  the  trachea  for  a  number  of  years.  \Miile 
such  evidence  is  valuable  when  present  it  must  not  be  taken  negatively. 
As  pointed  out  by  Iglauer  (Bib.  "223),  the  mere  size  of  a  foreign  body 
does  not  ])reclude  its  presence  in  the  trachea.  Determination  of  the 
position  of  an  esophageallv  lodged  foreign  body  by  the  sensation  of  the 
patient  is  exceedingly  misleading.  The  sensations  that  the  patient  feels 
may  be  those  of  the  spasm  excited  in  a  relatively  remote  position  in  the 
esophagus,  or  the  pains  of  other  sensations  may  be  reflected,  but  per- 
haps the  most  important  factor  is  that  the  sensations  of  the  esophagus 
are  of  a  very  ill-developed  kind.  Foreign  bodies  that  ha\e  lodged  in 
the  larynx  usually  cause  hoarseness  in  a  very  short  time,  and  the  cough 
is  apt  to  be  of  a  croupy  character.  If.  however,  the  foreign  body  is  of 
such  a  nature  as  to  prop  the  cords  apart  there  may  be  complete  aphonia, 
and  this  is  almost  diagnostic  of  a  laryngeally  lodged  foreign  body.  Se- 
vere dyspnea  also  usually  points  to  glottic  or  subglottic  lodgment.  For- 
eign bodies  in  the  larynx  are  usually  somewhat  painful  as  compared  to 
those  that  lodge  in  the  tracliea  and  bronchi,  which  are  painless.  There 
is  often  a  peculiar  character  to  the  cough  when  the  foreign  body  pre- 
vents glottic  closure  by  working  between  the  cords.  .\s  is  well  known, 
the  cords  approximate  and  the  cough  comes  with  an  exi)losive  effort. 
This  mechanism  is  interfered  with  by  the  proi)i)ing  apart  of  the  cords 
and  hence  the  cough  has  rather  the  sound  of  an  intubated  patient,  though 
only  to  a  slight  degree.  In  children  there  is  the  usual  tracheal  cough  ow- 
ing to  the  collajjse  of  the  tracheal  walls  during  the  expulsive  eftorts.  A 
very  hoarse,  croupy  cry  usually  means  reactionary  inflammation,  and  to 
the  trained  ear  there  is  a  peculiar  note  produced  in  most  cases  by  which 
Dr.  Ellen  J.  Patterson  and  the  author  have  been  able  to  diagnosticate  the 
presence  of  foreign  bodies  in  a  few  instances.  The  note  may  be  likened 
to  a  croupy  or}'  with  a  metallic  hiss  added,  though  this  description  is  in- 
aderiuate  to  anyone  who  has  not  heard  it.  We  do  not  know  what  pro- 
duces the  alteration  of  the  ordinary  croupy  sound,  unless  it  is  the  rush  of 


FORKIC.N   r.onil'.S  IN    AIU  AND  FOOD  I'ASSAGF.S.  317 

air  past  the  foreign  IkxIv.  In  one  such  case,  referred  to  us  by  Dr.  C.  C. 
Sandels,  the  sound  amounted  almost  to  a  whistle,  and  was  evidently  due 
to  the  rush  of  air  past  tlic  thin  edge  of  the  hollow  brass  cap  at  the 
"keeper-end"  of  a  safety-pin.  .\o  radiograph  had  been  taken  and  the 
diagnosis  of  foreign  body  in  the  larynx  was  made  by  us  solely  on  the 
modification  of  the  croupy  cry.  There  was  no  history  of  foreign  body 
and  the  family  and  their  physician  were  astonished  to  see  the  pin. 
Every  case  with  a  foreign-body  history  should  be  followed  up  closely 
until  the  foreign  body  is  located  either  in  the  body,  in  the  stools,  or  un- 
til it  is  coughed  up  as  the  case  may  be.  Under  no  circumstances  should 
it  be  forgotten  or  ignored  as  harmless  in  the  absence  of  symptoms. 

Indirect  examination.  When  a  patient  comes  in  complaining  of  hav- 
ing swallowed  a  pin  and  states  he  or  she  can  feel  it  "here,"  pointing  to  a 
location  in  the  neck  or  chest,  the  patient  should  be  placed  at  once  in  the 
recunibcni  position  and  ;i  mirror  examination  should  be  made  in  this 
irosition.  The  patieiil  should,  if  possible,  never  be  allowed  to  raise  the 
head  until  after  the  mirror  and  Roentgen-ray  examinations.  W  hen  there 
is  reason  to  suspect  that  a  foreign  body  has  entered  the  air  passages,  the 
patient  shoidd  be  kept  recumbent  and,  preferably,  face  downward.  Un- 
der no  circumstances  should  the  patient  be  allowed  to  sit  up  or  to  lie  on 
either  side.  The  reason  for  these  precautions  is  to  prevent  gravitation. 
If  the  patient  is  allowed  to  sit  erect,  the  foreign  body,  especially  if  of 
small  size,  will  fall  down  into  the  deepest  possible  bronchus.  If  tlie  pa- 
tient is  allowed  to  lie  on  the  back,  the  foreign  body  will  in\ade  one  of 
the  posterior  branches  which  are  exceedingly  diHicult  to  reach.  The  ob- 
jection to  lying  on  the  side  is  that  this  would  fa\or  the  foreign  body  en- 
tering the  u|)per  lobe  bronchus,  and  especially  \\(ju1(1  this  be  the  case  if 
the  foreign  body  should  already  be  in  one  side  and  be  dislodged  and  tak- 
en over  into  the  other  side,  lender  such  circumstances,  tlic  U])[)cr  lobe 
bronchus  would  be  almost  surely  invaded  if  the  patient  w  ere  at  the  time 
lying  uj)on  ihc  previously  nnin\adcd  side.  It  is  prol)al>le  that  lying  upon 
the  face  may  cause  the  foreign  body  to  enter  the  middle  lobe  bronchus, 
but  in  the  two  cases  of  foreign  bodies  in  the  middle  lobe  bronchus  in  the 
author's  cx[)erience  the  extractions  seemed  easier  than  in  cither  cases  in 
which  the  jiosterior  branches  of  the  inferior  lobe  bronchus  had  been  in- 
vaded. I'urther  evidence  afforded  by  additional  cases  mav  demonstrate 
that  middle  lube  bronchus  cases  are  not  easier.  In  this  e\ent  ddrs.il  n- 
cumbency  would  be  better,  but  there  can  be  no  (|Ucstion  that  recumbency 
is  advisable  because  of  the  well  proven  tendency  of  foreign  bodies  to 
work  (low  n\\;ird.  I'.ecause  of  the  briuiching  angle  of  the  middle  lobe 
bronchi  and  of  the  inferior  lobe  bmnchi,  respecli\ely,  in  relation  to  the 
long  axis  of  the  body,  ventral  recumbency  does  not  make  as  steep  a  de- 


218  FOREIGN  BODIES  IN   AIK  AND  FOOD  PASSAGES. 

clivity  into  the  middle  lobe  bronchus  and  its  branches  as  does  dorsal  re- 
cumbency into  the  dorsal  branches  of  the  inferior  lobe  bronchus.  The 
fact  of  there  being  but  one  middle  lobe  bronchus  also  diminishes  the 
chances  of  invasion  even  though  right  sided  invasion  is  more  frequent 
than  left  as  will  be  referred  to  later.  Next  in  importance  is  to  quiet  the 
fears  of  the  patient,  and  above  all  not  to  urge  the  patient  to  cough  in  the 
vain  hope  of  coughing  the  foreign  body  out.  Not  only  are  the  chances 
of  success  small,  but  the  chances  of  a  sharp  foreign  body,  such  as  a  pin, 
burying  its  point  are  great.  In  the  event  of  the  point  becoming  buried, 
there  is  very  apt  to  be  a  very  ratchet-like  action  by  which  the  pin  is 
forced  deeper  and  deeper,  the  point  i)reventing  upward  movement.  In 
case  of  foreign  bodies  more  or  less  cubical  or  globular  in  shape  there  is 
risk  that,  in  coughing,  the  foreign  body  may  be  jammed  in  the  subglottic 
space  and  thus  asphyxia  be  threatened.  The  rule  in  regard  to  keeping 
the  patient  recumbent  does  not  apply  to  foreign  bodies  definitely  located 
in  the  esophagus,  because  gravity  plays  little  or  no  part  in  the  downward 
mo\ement  of  anything  in  the  esophagus  under  normal  conditions.  When 
an  esophagoscope  is  introduced  conditions  are  altered.  Having  e.xam- 
ined  the  larynx  first,  to  make  sure  that  there  is  no  foreign  body  on  the 
brink  ready  to  fall  into  the  air  passages  below  should  the  patient  gag,  the 
tonsils  and  nasopharynx  and  neighboring  regions  should  be  carefully  ex- 
amined. In  all  of  this  inspection  preliminary  to  endoscopy,  abrasions  of 
possible  foreign  body  origin  should  be  looked  for ;  and  the  possibility  of 
certain  kinds  of  foreign  bodies,  as  needles,  headless  pins  and  the  like, 
having  entered  and  disappeared  into  the  tissues  should  be  borne  in  mind. 
In  such  cases  discovery  of  the  wound  of  entrance  is  of  the  utmost  im- 
])ortance  as  facilitating  remo\al  liy  pursuit  or  by  enlargement  of  the 
wound,  which  are  justifiable  in  these  higher  regions  in  certain  cases  as 
hereinafter  explained. 

I.ocalhation  of  esophageallv  lodged  foreign  bodies  ik'ith  the  bougie. 
Nothing  can  be  a  more  useless  waste  of  time  than  the  blind  jiassage  of 
a  bougie  in  an  esophageal  case,  whether  disease  or  foreign  bodv  is  sus- 
pected. It  usually  takes  less  time  to  pass  an  esophagoscope  and  remove 
the  foreign  body  or  a  specimen  of  neoplasm,  or  to  make  an  accurate 
diagnosis  of  disease  than  it  does  to  pass  the  bougie ;  after  the  passage 
of  which  one  usually  has  accomplished  nothing.  The  last  defense  of  the 
blind  bougie  for  diagnosis  is  based  upon  obsolete  conditions.  It  is 
claimed  that  thus  can  be  determined  the  length  of  esophagoscopic  tube 
required.  But  there  is  no  need  of  more  than  one  tube  for  adults  and 
one  for  children.  It  is  also  stated  that  high  disease  of  the  esophagus 
may  be  overridden  or  perforated  by  the  mandrin  of  the  esophagoscope 
unless  the  location  is  [ireviously  determined  by  blind  bouginage.     But 


FOREIGN   BODIES  IX   AIR  AND  FOOD  PASSAGES.  219 

there  is  no  need  of  a  mandrin  in  introducing  the  esophagoscope.  The 
esophagoscope  passed  by  sight  is  safer  than  the  bougie.  The  latter  is  a 
rehc  of  pre-esophagoscopic  days. 

RADIOGRAPHIC  LOCALIZATION  OF  FOREIGN  BODIES. 

The  author  is  quite  unfamihar  with  the  technicalities  of  Roent- 
genology, and  the  suggestions  herein  given  have  been  gleaned  from  ex- 
perience in  a  large  number  of  cases  of  foreign  bodies  (as  well  as  of  dis- 
ease) the  successful  outcome  of  which  has  been  due  to  marvelous  work, 
radiographic  and  interpretative,  of  such  eminent  Roentgenologists  as 
Cole,  George  C.  Johnston.  lioggs,  Hickey,  Grier,  Foster,  Gray,  Bowen.. 
Lang,  Menges,  Leonard,  Cassabian,  Pfahler.  Eynian,  Pancoast,  Holding 
and  others.  The  suggestions  here  given  are  intended  for  surgeons  who 
cainiot  avail  themselves  of  the  work  of  radiographic  experts.  After  hav- 
ing radiographically  located  a  foreign  body  we  must  always  remember 
the  possibility  of  the  foreign  body  having  changed  its  position  between 
the  time  the  ray  was  taken  and  the  bronchoscopy  is  done.  The  foreign 
body  may  have  shifted  to  another  bronchus,  or  it  may  be  even  in  a 
bronchus  of  the  opposite  side. 

Excellent  progress  has  been  made  in  the  radiographic  localization 
of  foreign  bodies.  This  is  especially  true  in  regard  to  the  technical  im- 
provements which  have  rendered  possible  the  practically  instantaneous 
radiography,  as  it  has  cjuite  recently  been  recognized  (Tilley,  Dundas 
Grant  and  others)  that  an  instantaneous  radiograph  will  often  show  for- 
eign bodies  not  visible  with  longer  exposures.  Moreover,  there  is  less 
chance  for  voluntary  and  involuntary  movements  of  the  patient, 
which  are  transmitted  to  the  foreign  body,  to  blur  the  outline  of  the 
intruder.  Esi)ecially  is  this  the  case  with  very  young  children  who  can- 
not be  expected  to  hold  their  breath  at  command.  Dr.  George  C.  John- 
ston has  a  number  of  times  gotten  a  plate  with  beautiful  definition  free 
from  respiratory  movement  in  an  extremely  dyspneic  child  with  heaving 
chest  by  snapping  a  number  of  momentary  exposures  at  the  respiratory 
rest  i)eriods  after  inspiration  and  before  expiration.  A  deep  inspiration 
held  during  the  exposure  creates  an  artificial  emphysema  which  causes 
the  foreign  body  to  show,  becai'se  it  lessens  the  density  of  the  thorax  : 
though  it  must  be  borne  in  mind  that  the  more  horizontal  position  of  the 
ribs  and  the  displacement  of  the  viscera,  including  the  foreign  body  must 
be  allowed  for  in  the  localization.  The  steady  progress  made  by  the 
radiograi)iier  in  lateral  radiography  of  the  thorax  has  not  only  been 
of  great  aid  in  the  general  localization  from  bony  and  visceral  landmarks, 
but  also  in  conjunction  with  the  caliper-guide  suggested  by  Dr.  Boyce 
and  ijcrfected  by  the  .-luthor. 


220 


FOREIGN  BODIICS  IX   AIR  AND  FOOD  PASSAGES. 


The  author  puqjosely  omits  a  talnilar  record  of  the  foreign  bodies 
that  might  be  expected  to  show  and  those  that  ]irobal)l\-  will  not  show. 
His  reason  for  the  omission  are : 

1.  The  casting  of  a  radiographic  shadow  depends  not  alone  upon 
the  density  of  the  foreign  body  but  upon  its  thickness  in  the  diameter 
parallel  to  the  rays.     .\n  example  of  this  is  seen  in  Fig.  160  and  101. 

2.  A  body  of  little  densit}'  or  diameter  may  happen  to  be  so  lo- 
cated that  Its  shadow  mav  not  lie  overlaid  bv  normal  shadows  so  that  it 


Fig.  i6o.  Radiograph  showing  bone  in  the  esophagus.  Note  the  swelling  at  the 
esophageal  walls  and  the  clear  outline  of  the  air  passages.  (Author's  case.  See 
Fig.  .y.l.    Plate  made  by  Dr.  George  C.  Johnston.) 


may  show.  The  author  has  seen  a  large  number  of  examples  of  tin- 
kind  which  are  not  here  reproduced  because  the  shadows  while  plainly 
shown  on  the  negatives  lose  too  much  in  reproduction  to  show. 

3.     Lesions  secondary  to  the  foreign  body  may  be  revealed  by  the 
radiograph  and  thus  enable  localization  as  in  the  case  cited  under  "Pul- 


KOKKICN  BODIKS  I  \  AIR  AM)  1"00»  I'ASS AGKS. 


231 


moiiary  Abscess,"  and  under  "I.ocalizalion  Films."  In  another  case  of 
the  aiulior  a  peanut  kernel  completely  occluded  the  left  upper  lobe  bron- 
chus producing  a  shadow  over  the  entire  left  upper  lobe,  though,  of 
course,  the  peanut  itself  did  not  show.  The  peanut  kernel  was  bron- 
choscopically  removed  from  just  within  the  orifice  of  the  upper  lobe 
bronchus,  liberating  a  large  quantity  of  purulent  secretion. 

4.     The  foreign  body  may  not  be  the  same  as  that  of  which  a  his- 
tory is  given.     The  most  common  example  of  this  is  the  pin  or  other 


Fit;.  161,  Railioiirapli  of  same  patient.  Tlic  piece  nf  1)(inc,  tlnuisli  present  at 
the  level  of  the  dart,  does  not  show,  partly  because  it  overlies  the  spine  but 
mainly  because  in  the  lateral  view  the  flat  foreign  body  is  seen  on  edge.  An  ex- 
ample of  the  misleadmg  negative  radiograph,  and  an  indication  for  lateral  as  well 
3S  antcro-posterior  radiography. 


dense  object  whicli  has  gotten  into  food  and  which,  from  the  sensations 
and  from  its  presence  in  sou|)s.  etc..  tiie  patient  refers  to  as  a  "bone."' 

For  the  foregoing  reasons  the  .luthor,  e.xcept  in  cases  of  great  ur- 
gency, has  a  radiograph  taken  of  every  case.  L'nless  the  radiographic 
tube  happens  to  be  ])!accd  exactly  on  a  line  that  passes  through  the  for- 
eign body  and  that  is  exactly  vertical  to  tlie  plate,  there  will  be  a  mis- 
leading distortion  as  to  the  ])osition  of  the  foreign  body  relatively  to 
anatomic  shadows  :  because  the  rays  passing  the  foreign  body  at  a  cer- 
tain angle  will  continue  to  tra\el  at  that  angle  until  they  reach  the  plate. 


222  FOREIGN  BODIES  I.V  AIR  AND  FOOD  PASSAGES. 

Therefore,  the  (hstortion  will  be  in  direct  ratio  to  the  distance  of  the 
foreign  body  from  the  plate,  and  also  in  direct  ratio  to  the  distance  of 
the  foreign  body  from  any  landmark,  anatomic  or  artificial.  While  de- 
ceptive, if  misunderstood,  or  if  the  position  of  the  tube  is  unknown,  this 
distortion  has  been  turned  to  good  account  by  enabling  eminent  Roent- 
genologists (Johnston,  Cole,  Boggs,  Grier,  Pfahler.  Boetjer  and  others) 
to  work  out  plans  of  localization  by  triangulation  and  otherwise,  by  means 
of  which  the  precise  depth  from  any  surface  landmark  desired  can  be 
determined  to  a  nicety.  In  one  case,  in  which  a  foreign  body  was  buried 
in  the  inflammatory  new-tissue  produced  during  a  ten  years'  sojourn, 
the  author's  successful  extraction  of  the  foreign  body  was  due  to  Dr. 
L.  G.  Cole's  accurate  localization.  In  a  similar  case  Dr.  Alenges  en- 
abled the  author  to  find  a  foreign  body  of  seven  years'  sojourn.  In  quite 
a  number  of  instances  Drs.  Johnston.  Grier,  Boggs  and  others  have 
similarly  rendered  removals  possible.  The  limitations  of  this  method  of 
localizations  are  reached  when  we  encounter  foreign  substances  not 
opaque  to  the  ray.  Borderline  cases  are  those  in  which  the  body  is  not 
sufficiently  dense  to  show  in  more  than  one  position  of  the  patient,  as  in 
a  case  of  the  author  (reported  on  a  future  page)  in  which  a  glass  collar 
button  could  be  shown  only  in  a  quartering  lateral  exposure,  between  the 
heart  and  the  spine.  Fortunately,  a  very  remarkable  radiograph  in  this 
position  by  Dr.  George  C.  Johnston  not  only  revealed  the  collar  button, 
but,  by  showing  the  trachea  and  bronchi,  and  still  more  wonderful  the 
inflammatory  new  tissue  which  blocked  the  bronchus  above,  enabled  the 
author  endoscopically  to  cut  away  the  intervening  inflammatory  obstruc- 
tion to  gain  access  to  and  remove  the  foreign  body.  A  radiograph,  first 
in  the  anteroposterior  plane  and  then  in  the  lateral  plane,  has  been  very 
valuable  in  assisting  in  a  localization  of  a  foreign  body  with  reference 
to  a  bronchoscope  inserted  to  a  certain  definite  location,  which  is  fixed 
in  the  memory  of  the  bronchoscopist  so  that  he  can  find  the  same  loca- 
tion at  a  subsequent  bronchoscopy  (Fig.  ]li2).  In  doing  this  work,  it 
is  essential  that  no  anesthetic  ether  be  used,  because  of  the  inflammabil- 
ity of  ether  which  might  be  ignited  by  a  spark.  If  the  foreign  body  is 
very  dense  to  the  ray  the  fluorescent  screen  may  be  used  with  results  that 
are  immediately  available  for  work  without  withdrawal  of  the  broncho- 
scope. Of  course  this  method  by  either  radiography  or  fluoroscopy  is 
available  only  in  case  of  foreign  bodies  dense  to  the  ray.  Manv  foreign 
bodies  that  are  sufficiently  opacjue  to  show  in  a  radiograph  are  insuffi- 
ciently dense  to  show  in  the  fluoroscope.  Localization  by  means  of  a 
radiograph  of  the  instrument  in  position  at  the  suspected  locality  has 
been  used  by  the  author  in  cases  of  pulmonary  abscess  (Fig.  I'.Mi).  The 
same  method  may  be  used  in  esophageal  cases  in  which  the  foreign  body 


FOREIGN  BODIKS  IN  AIR  A  Nil  I'OOD  PASSAGES. 


223 


Fig.  162.  Antcro-posterior  and  lateral  radiograph  of  recumbent  patient  with 
bronchoscope  in  position.  Useful  for  localization  in  case  of  small  foreign  bodies 
SO  far  down  and  far  out  toward  the  periphery  that  they  cannot  be  found.  The  po- 
sition and  direction  of  the  intruder  from  the  tube  mouth,  which  is  at  a  known  and 
subsequentlv  lindalile  location,  locates  the  small  branch  bronchus  to  be  searched  at 
a  subsequent  bronchoscopy.  With,  dense  foreign  bodies  like  the  pin  above  shown, 
the  fluorescent  screen  may  be  used,  yielding  immediate  information. 


22-1:  FORl-ICX  BODIHS  IN   AIR  AND  roOD  PASSAGES. 

is  suspected  to  have  wandered  out  of  the  himen  into  the  tissues.  Care 
must  be  taken  to  avoid  error  from  a  foreign  body  being  simply  in  a 
fold  in  the  lumen.  A  large  esophagoscope  should  eliminate  this  jiossi- 
hility.  A  sulisequent  radiograph  with  pressure  of  the  tube-mouth  against 
the  pin  will  give  positive  evidence.  A  lateral  as  well  as  an  antero-pos- 
terior  radiograph  are  necessary  in  any  case. 

The  statements  in  the  earlier  work  (Bib.  2G9)  in  regard  to  unre- 
liabilit_v  of  fluoroscopy  as  compared  to  radiography  for  foreign  bodies 
have  been  borne  out  by  further  experience.  A  foreign  body  overlying 
the  spine  or  behind  the  heart  shadow  may  be  invisible  by  fluoroscopy  and 
yet  show  up  strongly  in  such  a  location  in  the  radiograph.  In  one  in- 
stance, a  pin  behind  the  heart  shadow  showed  as  black  as  if  drawn  with 
a  pen  in  a  radiographic  print,  and  yet  was  totally  invisible  to  an  ex- 
perienced fluoroscopist  with  a  proper  tube.  This  was  in  an  infant,  and 
therefore  a  very  advantageous  subject  in  which  to  see  a  foreign  body  on 
the  screen.  With  such  results  as  these  among  the  possibilities,  it  is  use- 
less to  waste  time  with  fluoroscopv  for  diagnosis  as  to  the  presence  of  a 
foreign  body,  because  with  the  instantaneous  exposures  and  rapid  de- 
veloping of  to-day.  a  report  may  be  had  in  i)0  minutes  or  less  from  the 
time  the  radiograph  is  taken.  Fluoroscopy,  however,  may  be  of  advan- 
tage in  foreign  body  cases  in  adults  for  another  reason.  An  expert 
fluoroscopist  v.ith  the  recently  developed  apj^aratus  can  exclude  aneurysm 
and  give  a  report  on  the  functional  acti\ity  of  the  esophagus.  With 
foreign  bodies  not  opaque  to  tlie  ray  at  times  information  can  be  ob- 
tained from  fluoroscopic  examination  of  the  action  of  the  diaphragm. 
Under  average  conditions  there  may  be  a  slightly  greater  activity  of  one 
side  as  compared  to  the  other,  but  any  marked  diminution  of  the  ex- 
cursion of  the  diaphragm  on  one  side  points  to  foreign  body  obstructing 
the  main  bronchus.  This  is  not  diagnostic  but  is  a  strong  indication  for 
bronchoscopy.  Fluorescent  bronchoscopy  in  which  the  bronchoscope  and 
forceps  arc  guided  by  the  fluorescent  shadow  will  be  dealt  with  in  a  sub- 
sequent chapter. 

In  case  of  a  foreign  body,  which,  from  its  nature,  would  show  very 
faintly,  if  at  all,  in  the  radiograph,  the  suggestion  of  Boyce  to  swallow 
a  bismuth  capsule,  is  excellent.  If  the  foreign  body  is  sufticiently  large 
to  be  at  all  obstructive,  the  capsule  will  stop  and  remain  at  least  for  a 
time  at  the  site  of  the  foreign  body.  (Fig.  16:5).  This  not  only  shows 
that  the  foreign  body  is  present,  but  it  shows  its  position,  and,  further- 
more, on  dissolving  of  the  capsule,  the  liismuth  is  beneficial  to  any  trau- 
matism or  esophagitis  that  may  exist  in  the  neighborhood  of  the  for- 
eign body.  In  using  the  Ijismuth  capsule,  for  the  detection  of  a  foreign 
body  not  itself  opaque  to  the  ray,  it  is  necessary  to  remember  that  the 


I'ORUIGX    BODIES    IN    AIU    AND   FOOD    PASSAGES. 


225 


progress  downward  of  a  bismuth  capsule  or  any  large  bolus  is  not  ex- 
ceedingly rapid  and  may  normally  be  seen  in  transit.  Still  more  neces- 
sary is  it  to  remember  that  in  many  cases,  with  a  perfectly  normal  esoph- 
agus not  containing  any  foreign  body,  the  capsule  may  hesitate  for  a 
moment  at  the  cricopharyngeus  and  also  at  the  point  where  the  left 
bronchus  crosses  the  esophagus,  and  again  at  the  hiatus.  The  author  has 
noted  in  quite  a  number  of  cases  with   an  apparently  perfectly  normal 


Fig.  16,3.  kadio.uraph  sliowiiig  a  mctlii>d  of  locating  a  foreign  body  in  the  eso- 
phagus. The  bismutli  capsule  was  slopped  in  the  esophagus  by  a  foreign  body  that, 
itself,  does  not  show. 


esophagus  that  the  ridge  caused  by  the  crossing  of  the  left  bronchus  was 
undtilv  prominent,  and  this,  in  one  case,  was  connected  directly  with  a 
lodgment  of  the  bismuth  capsule  for  a  few  seconds  in  an  esophagus  which 
did  not  contain  ri  foreign  body.  In  view  of  this,  it  would  seem  to  be  wise 
in  using  the  capsule  for  the  diagnosis  of  foreign  bodies  not  opaque  to 
the  rav  to  wait  two  or  three  minutes  after  swallowing  the  capsule  before 


226  Foreign  eddies  ix  air  and  food  passages. 

taking  a  radiograph  ;  but,  of  course,  the  wait  must  not  be  sufficiently  long 
to  permit  of  the  capsule  dissolving.  In  case  of  small  non-obstructive 
foreign  bodies  the  metliod  would  not  be  efifective,  and  in  any  case  is  value- 
less negatively.  \\'hen  positive  it  may  be  so  from  an  obstruction  other 
than  a  foreign  body. 

Interpretation  of  a  radiograph  is  best  done  by  the  radiographer ;  a 
few  hints  to  the  endoscopist,  however,  may  not  be  amiss.  First  in  im- 
portance is  to  determine  whether  the  foreign  body  is  in  the  respiratory 
or  in  the  alimentary  tracts,  and  next  in  importance  is  to  determine  in 
what  part  of  the  respective  passages  the  foreign  body  is  lodged.  This 
is  extremely  easy  in  some  cases,  extremely  difficult  in  others.  As  a 
rule,  it  may  be  stated  that  foreign  bodies  more  or  less  flat,  whose  plane 
corresponds  to  the  lateral  plane  of  the  body,  are  in  the  esophagus  and 
not  in  the  air  passages.  This  applies  with  a  special  force  to  the  upper 
half  of  the  esophagus  because  the  esophagus  is  collapsed  antero- 
posteriorly ;  that  is,  the  anterior  wall  lies  against  the  posterior  wall.  The 
direction  of  least  resistance  being  laterally,  flat  foreign  bodies  project 
their  longest  diameter  laterally.  In  the  trachea,  also,  there  is  a  slightly 
greater  diameter  laterally  at  the  bifurcation  and  for  some  distance  above 
it.  Above  the  sternal  notch,  however,  foreign  bodies  entering  through 
the  glottis  are  almost  always  found  to  have  taken  the  anteroposterior 
position  because  of  the  greater  axis  sagittally  of  the  laryngeal  and  sub- 
glottic lumina ;  and  this  position  is  most  likely  to  be  maintained 
below,  because  the  posterior  wall  of  the  trachea  is  membranous  and 
yielding.  These  points  are  well  illustrated  in  the  radiographs  Figs.  1(34 
and  Kio,  and  are  especially  plainly  marked  in  lateral  radiographs  of  for- 
eign bodies  in  the  esophagus  as  illustrated  in  various  parts  of  this  book. 
It  is  customary  in  the  interpretation  of  a  radiograph,  when  one  lung 
shows  dark  and  the  other  light,  to  consider  that  the  dark  side  contains 
the  foreign  body  which  has  occluded  the  main  bronchus  with  perhaps 
compensator}-  emphysema  on  the  opposite  side.  Iglauer  (Bib.  222)  re- 
ports a  very  interesting  case  where  this  reading  was  erroneous  because 
the  foreign  body  had,  by  a  vahe-like  action,  imprisoned  more  air  in  the 
obstructed  side,  so  that  there  was  a  verv  marked  emphysema  shown  by 
the  radiograph  on  the  obstructed  side. 

Calcified  glands  are  exceedingly  common  and  may,  in  some  instances, 
lead  to  error.  As  pointed  out  by  Dr.  George  C.  Johnston,  in  connection 
with  one  of  the  author's  cases,  that  of  a  molar  tooth  in  the  bronchus  of 
a  boy,  calcified  glands  are  always  rounded  in  form,  so  that  in  case  of  any 
body  not  of  rounded  form,  there  is  little  likelihood  of  error ;  but  it  must 
be  remembered  that  the  foreign  body  must  be  considered  from  every 
point  of  view,  as  irregular-shaped  bodies  may  throw  a  rounded  shadow  in 


FOREIGN  BODIES  IN  AlK  AND  l-(X)I)  PASSAGES. 


327 


certain  positions.  Furthermore,  calcilicd  f,'lands  arc  rarely  single,  so 
that  any  suspicious  shadow  is  apt  to  he  duplicated,  if  due  to  a  calcified 
gland.  Von  Eicken,  in  a  very  interesting  paper  (Bib.  oliS),  reports 
a  case  in  which  a  shadow  was  thought  by  the  Roentgenologist  to  be  due 
to  a  calcified  gland,  and  so  it  proved  to  be.     There  was,  nevertheless,  in 


Fic.  164.  Radiograph  of  a  coin  (half-dollar)  in  the  esophapus  of  a  child  of 
14  years.  This  illustrates  the  method  of  localization  of  foreign  bodies  in  the  esoph- 
agus. It  is  utterly  impossible  for  a  Hat  body  of  this  size  to  be  trachcally  lodged 
thus  in  the  lateral  plane  of  the  trachea. 


the  case  a  forei.^n  liody   (hone)   which  did  not  siiow  in  the  radiograph, 
but  which  was  discovered  and  removed  by  bronchoscopy. 

Posith'c  films  of  the  tracheo-bronch'ml  tree  as  an  aid  to  localization. 
A  large  foreign  bod_\-  in  a  large  bronchus  needs  accurate  localization,  not 
but  that  it  could  be  limnd  bronchoscopically  in  every  case;  but  accur- 
ate localization  enables  tiie  bronchoscopist  to  go  at  once  to  the  known  lo- 
cation and  thus  greatly  shorten  the  period  of  endoscopic  search  which 


22S 


FOREIGN    BODIES    IN    AIR   AND    FOOD    PASSAGES. 


FOREIGN   BODIi:S   IN   LARYNX  AND  TRACHKA. 


239 


may  be  a  vital  point.  'J'hcre  is  another  class  of  cases,  howe\er,  in  which 
the  intnider  may  never  be  found  if  there  has  been  no  accurate  localiza- 
tion. Small  foreign  bodies,  or  those  small  in  one  diameter,  following  the 
general  rule  of  foreign  bodies  in  the  air  passages,  keep  on  going  down- 
ward until  they  get  into  the  smallest  possible  bronchus.  Thus  needles 
and  small  headed  pins  get  very  far  down  and  \ery  far  out  toward  the 
perijihery  of  the  lung  and  into  a   very  small  branch  bronchus  of  which 


Fig.  i66.  Illustration  of  a  positive  film  used  for  overlaying  to  assist  in  lo- 
calization of  foreien  bodies  or  lesions  in  the  thorax.  The  lower  white  line  (  U, 
D)  corresponds  to  the  diaphragm,  the  nrddlc  line  (1'  1')  In  ihe  dome  of  the 
pleura.  These  Hnes  assist  in  placing  the  overlay.  The  upper  line  (V  C),  cor- 
responding to  the  vocal  cords,  is  occasionally  useful.  Twelve  photographic  en- 
largements arc  on  hand  so  that  a  film  of  the  size  (rather  than  the  age)  is  avail- 
able for  any  sized  patient.  The  few  minute  branches  that  go  below  the  line,  D. 
are  those  posterior  to  the  apex  of  tl.e  dome. 


there  are  many.  To  search  all  nf  ilicsc  with  a  probe  or  niiiuiie  tube  con- 
sumes a  large  amount  of  lime.  The  atithor  has  devised  ior  help  in  these 
cases  a  positive  transparent  film  of  the  tracheo-bronchial  tree  (  b'ig.  HWi). 
The  film  being  a  "positive"  the  tree  is  transparent.  The  him  is  laid  over 
the  negative  of  the  ])atienl  sliowiiig  the  foreign  I'odv.  when  the  foreign 
body  will  show  through  the  transparent  tracheo-bronchial  tree  of  the 
ovcrlving  positive  film.     In  pl.acing  the  film,  bony  landmarks  are  not  re- 


230 


FOREIGN  BODIES  IN  AIR  AND  FOOD  PASSAGES. 


liable  because  of  the  wide  variation  due  to  the  phylogenetic  recency  of 
the  upright  posture.  X'isceral  landmarks  are  necessary.  The  two  im- 
portant visceral  landmarks  are  the  dome  of  the  pleura  and  the  dome  of 
the  diaphragm.  It  is  needless  to  say  the  tracheo-bronchial  tree  necessarily 
lies  in  the  body  of  the  lung  between  these  two  landmarks,  and  lines  cor- 
responding to  these  are  placed  on  the  film.  Twelve  photographic  enlarge- 
ments and  reductions  are  on  hand  so  that  a  film  of  the  size  (rather  than 
age)  is  available  for  any  sized  patient,  the  size  being  chosen  by  matching 
the  size  between  the  dome  of  the  pleura  and  that  of  the  diaphragm  as 
shown  on  the  radiograph  of  the  patient.  All  this  work  is  done,  of  course, 
in  a  darkened  room,  with  a  stronglv  illuminated  shadow-box;  and  in  the 


Fig.  167.  Ilhi.'itratii,!.'  on  tlie  left,  aliscess  ( rctouclicd).  On  the  right  the  abscess 
is  localized  in  the  right  inferior  lolje  bronchus  by  the  method  of  overlaying.  The 
localization  coincided  with  the  endoscopic  findinus'when  the  abscess  was  evacuated 
bronchoscopically. 


event  of  the  foreign  body  showing  very  faintly  on  the  radiograph  of  the 
patient,  it  is  strengthened  by  an  ink-mark  on  tlie  uncoated  side  of  the 
negative,  which  can  be  readily  erased  afterwards  if  desired. 

Corroboration  of  the  usefulness  of  these  films  has  been  forthcoming 
from  a  number  of  sources.  (See  article  by  R.  C.  Lynch  in  New  Urleans 
Med.  and  Surg.  Journal,  Dec,  1913). 

To  prevent  error  in  the  use  of  these  films,  as  with  any  method  of 
interpretation  of  a  radiograph,  it  is  necessary  to  be  on  guard  against 
false  localization  due  to  displacement  of  the  lung  by  atelectasis,  and  es- 
pecially by  the  compensatory  emphysema  on  the  other  side.  Another 
source  of  error,  of  course,  is  that  the  positives  of  the  tracheo-bronchial 
tree  are  made  from  the  tracheo-bronchial  tree  of  a  cadaver,  whereas 
bronchoscopic  study  of  the  tree  shows  that  it  is  not  quite  in  the  same 


FOREIGN  BODIES  IN  AIR  AND  FOOD  PASSAGES. 


231 


position  in  the  living.  The  injection  prejiarations  of  I'.runings  come 
nearer  those  of  the  li\ing  tree  than  any  other  that  the  author  has  been 
able  to  find,  and  therefore  he  has  used  them  in  making  the  positive  films. 
Caliper-guide  method  of  localization.  This  method,  suggested  by 
Dr.  John  \\".  Boyce  and  perfected  by  the  author  is  intended  primarily  for 
bringing  the  tube  mouth  in  close  relation  with  a  small  foreign  body  that 
cannot  be  found  because  it  is  in  a  minute  bronchus  of  which  there  are 
too  many  for  each  to  be  searched.  In  conjunction  with  the  lateral  radio- 
graph the  caliper-guide  will  bring  the  point  of  the  bronchoscope,  after- 
ward at  bronchoscopy,  in  close  relation  with  the  foreign  body,  thereby 
greatly  diminishing  the  number  of  small  bronchial  tubes  to  be  searched ; 
this  method  being  used,  of  course,  onlv  in  case  of  small  foreign  bodies 


Fig.  i68.  lUustratitiK  a  positive  radinRraphic  film  of  tlic  traclico-hroiicliial  tree 
u.sed  for  overlayincr  to  assist  in  localization  of  a  foreign  1)0(ly.  The  left  hand  illns- 
tration  shows  the  lilm  laid  over  a  negative  of  a  patient  in  whose  left  main  hronclms 
was  a  pin.  Localization  verified  by  bronchoscopy.  The  shadow  of  the  pin  is 
strengthened  with  ink. 


which  have  fallen  into  a  very  small  bronchus  far  down  or  far  out  near 
the  periphery  of  the  lungs.  The  lateral  placement  of  the  point  of  the 
bronchoscope  depends  ujion  a  m;irk  placed  on  the  skin  by  the  radio- 
grapher who  determines  the  |iiiiin  liy  an  anterior-posterior  radiograph 
(Fig.  Ifiti). 

Value  of  luuiativc  radiography.  The  negative  rejjort  from  liie  radio- 
grapher remains  to-day  as  it  always  has  been,  unreliable,  I)ecause  many 
bodies  are  not  opaf|ue  to  the  ray,  and.  moreover,  the  foreign  body  may 
not  be  the  same  as  that  of  which  we  get  ;i  history.  In  addition  to  this, 
even  metallic  bodies  at  times  do  not  show,  b'or  instance,  in  one  of  tlie 
author's  cases,  that  of  an  enormous  woman  of  Tv.\  years,  expert   radio- 


233  FOREIGN    BODIES    IN    AIR    AND   FOOD    PASSAGES. 

graphers,  for  a  period  of  two  years,  made  quite  a  number  of  exposures 
that  failed  to  demonstrate  a  tack  which  they  finally  demonstrated  to  be 
present  (Fig.  ]70)  and  which  the  author  removed  bronchoscopically. 
Such  occurrences  will  doubtless  be  less  and  less  frequent  because  of  the 
steady  advance  in  the  technical  perfection  of  radiography.    A  number  of 


Fig.  169.  Illustrating  llie  position  of  the  caliper-giiiile  in  getting  the  adjust- 
ments by  which  the  point  of  the  bronchoscope  can  be  brought,  later  at  bronchos- 
copy, in  close  proximity  to  a  foreign  body.  For  use  in  case  of  small  foreign 
bodies  in  minute  bronchi.  Suggested  l)y  Dr.  John  \V.  Boyce  and  perfected  by  the 
author.  Inadvertently,  in  making  the  illustration,  a  radiograph  of  an  esophageal- 
ly  lodged  foreign  body  (safety-pin)  was  used,  but  the  principle  is  illustrated  just 
as  well. 

recent  cases  have  made  it  quite  clear  tiiat  it  is  necessary  to  do  a  bronchos- 
copy if  there  is  any  reason  to  suspect  from  the  history  that  there  is  a 
foreign  body  located  somewhere  in  the  air-passages  or  in  the  esophagus, 
notwithstanding  a  negative  ray  finding  and  a  total  absence  of  symptoms, 
for  it  is  remarkable  how  tolerant  the  trachea,  bronchi  and  the  esophagus 
become  to  the  presence  of  foreign  bodies  after  the  initial  symptoms  im- 


I"I)RKIGN  HODIi:s  IN  AIK  AND  Kndl)  PASSAGES. 


233 


mediately  following  the  accident  liavc  subsided.  A  negali\-e  .\-ray  may 
be  very  misleading,  because,  as  shown  by  b'rank  C.  Todd  (  llib.  ."ill)  a 
radiograph  may  not  include  the  region  in  which  a  foreign  body  is  located. 
Xotwilhstanding  the  fact  that  there  was  no  clear  history  of  a  foreign 
body  having  been  seen  in  the  child's  possession,  and  despite  the  negative 
radiograph,  Dr.  Todd  bronchoscoped  the  child  without  a  general  anes- 
thetic and  skilfnlly  remo\-ed  the  tack.     j.  W.  .Murphy  (Rib.  3!IT)  reports 


P'li;.  I/O.     kiuiioyraph  .showing  tack  in  lironclnis 


a  woman 


'•  5,i  years.  This 


tack  failed  to  show  in  radiographs  taken  by  expert  radiographers  at  intervals  for 
a  period  of  two  years  before  getting  the  tack  to  show.  Tack  rciTiovo<l  lironcho- 
tcopically  by  the  author. 


experiments  demonstrating  the  fact  that  the  ei  impnsitiim  nf  wliich  most 
buttons  are  mafle  did  nf)t  show  in  the  radiograph,  and  ili.ii  with  phy- 
sical signs,  sensations  of  the  ])atient,  and  the  radiograph  all  negative,  the 
foreign  body,  nevertheless,  was  present.  In  one  of  the  author's  cases 
(illustrated  on  a  subsequent  page)  the  metal  |iart  of  a  shoe  button 
showed  but  the  composition  i)art  clid  not.  As  before  mentioned  it  is 
needless  here  to  consider  in  detail  the  different  kinds  of  foreign  body  as 


234  FOREIGN  BODIES  IX  AIR  AND  FOOD  PASSAGES. 

to  their  density  to  tlie  ray,  because  a  radiograpli  sliould  be  taken  in 
every  case;  and  if  negative  an  endoscopy  should  be  done  anyway  if  there 
is  reason  to  suspect  a  foreign  body.  Those  who  are  interested  in  the 
relative  densities  are  referred  to  the  interesting  article  of  von  Eicken 
(Bib.  5G3). 

Pliysical  c.vamhiatioii  of  the  chest.  Should  the  foreign  body  be 
located  by  radiograph,  physical  examination  of  the  chest  is,  nevertheless, 
necessary  for  two  reasons.  1.  The  data  to  be  obtained  will  be,  when  suf- 
ficient has  been  accumulated,  invaluable  for  other  cases  in  which  the 
foreign  body  is  not  dense  to  the  ray.  2.  The  condition  of  all  the  viscera 
in  the  thorax  and  elsewhere  should  be  known  before  endoscopy.  The 
notes  on  the  physical  signs  of  foreign  body,  by  Dr.  J.  W.  Boyce  (Bib.  2U!', 
p.  !Hi),  have  stood  the  test  of  further  experience.  In  case  of  complete 
occlusion  of  one  bronchus,  there  may  be  a  verv  marked  diminution  of  the 
respiratory  excursion  of  the  thorax  on  the  attected  side,  as  observed  by 
Dr.  John  R.  Simpson  in  one  of  the  author's  cases.  The  same  signs  have 
since  been  obser\-ed  in  a  number  of  other  cases.  The  author  is  \itterly  in- 
competent to  make  a  physical  examination  of  the  chest  by  auscultation  and 
percussion.  But  comparing  the  findings  of  verv  competent  physical  diag- 
nosticians with  the  author's  endoscopic  findings,  he  is  strongly  impressed 
with  the  fact  that  foreign-body  cases  are  nearly  always  associated  with  a 
large  amount  of  secretion  because  of  the  difticulty  in  expectoration,  and 
especially  is  this  the  case  in  children.  In  some  instances,  physical  signs  of 
solidification  have  completely  cleared  up  after  the  author  has  bronchoscop- 
ically  removed  a  large  quantity  of  secretion.  This  accumulation  of  secre- 
tion is  especially  liable  to  occur  in  the  lower  lobe,  and  (H.  T.  Price)  it 
may  be  limited  to  one  lower  lobe  even  when  the  foreign  body  is  in  the 
trachea.  In  some  instances  the  intruder  was  known  to  have  been  in  the 
trachea  for  a  number  of  weeks.  This  prolonged  sojourn  negatives  the 
hypothesis  that  the  foreign  body  might  have  been  in  a  lobe  of  one  lung  at  a 
previous  time,  resulting  in  the  excessive  secretion.  It  seems  certain  that 
the  secretion  had  tlrained  downward  and  accumulated  because  of  the  dit+i- 
cult  expectoration,  an<l  that  some  peculiarity  either  in  form  or  position  of 
the  right  or  the  left  bronchus,  or  some  ditterence  in  ciliary  action  has  fa- 
vored the  greater  accumulation  on  one  side  as  compared  with  the  other.  A 
number  of  interesting  facts  bearing  on  the  physical  signs  produced  by  the 
lesions  following  [prolonged  sojourn  of  a  foreign  body  in  the  lung  will  be 
given  along  with  the  case  reports  in  the  section  devoted  to  this  class  of 
cases.  The  similarity  to  the  physical  signs  of  pulmonarj-  tuberculosis  is 
remarkable.    Bronchiectasis  may  be  jiresent  with  its  jihysical  signs.* 

*\  unique  case  in  which  Dr.  George  I^.  Richards  di.iErnosticated  a  foreian  body 
on  physical  and  laboratory  findings,  in  the  absence  of  a  history,  is  recorded  in  the 
iransactions     of     the     American    Laryngological,     Rhinolog-ical     and     Otologleal 


I'OKi:u'.N    I'.iiDIKS  IN   AIK  AXD  FDiiD  I'ASSACKS.  235 

ERRORS  TO  AVOID  IN  SCSPnCTKI)  I'ORElGN-liUUY   CASKS. 

1.  Do  not  reach  for  the  foreign  hody  with  the  finger,  lest  the  foreign 
body  be  thereby  pushed  into  the  larynx,  or  the  larynx  be  thus  traumatized. 

2.  Do  not  make  any  attempt  at  removal  with  the  patient  in  any  posi- 
tion other  than  recumbent  witli  the  head  and  shoulders  lower  than  the 
body  (Fig.  T:!a). 

;>.  Do  not  h(jld  uji  the  patient  by  the  heels,  lest  the  foreign  body  be 
dislodged  and  asphyxiate  the  patient  by  becoming  jammed  in  the  glottis. 

•1.  Do  not  fail  to  have  a  radiograph  made,  if  possible,  whether  the 
foreign  body  in  (|uestion  is  of  a  kind  dense  to  the  ray  or  not. 

').  Do  not  fail  endoscojjically  to  search  for  a  foreign  bmly  in  all 
cases  of  doubt. 

I'l.  Do  not  pass  an  esophageal  bougie,  probang  or  other  instrument 
l)lindly. 

7.  Do  not  tell  the  patient  he  has  no  foreign  bod\-  until  after  radio- 
graphy, i)hysical  examination,  indirect  examination,  and  endoscopy  all 
have  proven  negative. 


CHAPTER     XIII. 

Foreign  Bodies  in  the  Larynx  and 
Tracheobronchial  Tree. 

Etiology.  In  the  air  passages,  which  are  not  intended  for  sohds. 
foreign  bodies  that  get  in  through  natural  passages  can  only  do  so  by 
passing  the  normal  safeguards  which  are  mainly  reflexes.  Hence  any- 
thing which  interferes  with  these  reflexes  is  the  chief  etiologic  factor. 
Sleep,  anesthesia,  intoxication,  syncope,  delirium,  mechanical  mterference 
of  masses  of  disease  as  in  malignancy,  tuberculosis,  etc.  The  reflexes 
may  interfere  with  each  other ;  as,  for  instance,  the  sudden  inhalation 
which  precedes  or  follows  coughing,  laughing,  sobbing,  and  unusual  ex- 
ertion. The  protective  reflexes  act  chiefly  in  two  groups.  The  laryngeal 
closing  reflex  and  the  bechic  reflex.  Laryngeal  closure  for  normal  swal- 
lowing is  chiefly  in  the  tilting  and  closure  of  the  upper  laryngeal  orifice. 
The  ventricular  bands  help  but  slightly  and  the  epiglottis  and  the  vocal 
cords  not  at  all.  Foreign  bodies  going  in  with  the  inspiratory  blast,  must 
run  the  gauntlet  of  the  following  guards  : 

GAUNTLET    TO    BE    RUN    BY   FOREIGN   BODIES   ENTERING    THE   LOWER   AIR 

PASS.\GES. 

1.  Epiglottis. 

2.  upper  laryngeal  orifice. 

3.  Ventricular  bands. 

4.  Vocal  cords. 

5.  Bechic  blast. 

The  epiglottis  makes  somewhat  of  a  fender,  efficient  in  projiortion  as 
it  hangs  backward  toward  the  posterior  pharyngeal  wall.  The  upper 
lary-ngeal  orifice,  composed  of  a  pair  of  movable  ridges  of  tissue  has  al- 
most a  sphincteric  action,  besides  its  tilting  movement.  The  ventricular 
bands  can  appro.ximate  under  powerful  stimuli.  The  vocal  bands 
act    similarly.       The    one    defect    in    the    etificiency    of    both     sets    of 


FOREIGX   i;oi)Ii;s   IN  LAKVXX  AND  TRACHEA.  237 

bands  in  barrinj;;  out  intruders  is  the  tendency  to  take  an  inspiration  pre- 
paratory to  the  cough  excited  by  the  contact  of  a  foreign  body.  This 
inspiration  is  not  invariably  taken,  however.  A  sHght  explosive  cough 
can  be  taken  without  inspiration,  especially  if  it  start  near  the  end  of  an 
inspiration,  but  following  this  or  any  other  coughing  effort  is  a  deep  in- 
spiration which  is  i)robably  the  most  etticient  factor  in  the  entrance  of 
foreign  bodies  into  the  lower  air  passages. 

Gottstein  collected  statistics  which  showed  that  (i(i  per  cent  of  the 
cases  of  foreign  bodies  in  the  air  passages  occurred  in  children.  This 
may  be  in  part  due  to  a  less  degree  of  automatic  protection  to  the  en- 
trance of  foreign  bodies  in  the  air  passages;  but  doubtless  is,  to  a  greater 
extent,  due  to  the  fact  that  children  are  prone  to  I'lay,  run,  laugh  and 
attempt  to  speak  with  various  foreign  bodies  in  the  mouth.  It  does  not 
seem  probable  that  children  put  foreign  bodies  in  their  mouths  more  fre- 
quently than  adults  when  it  is  considered  how  many  women  are  in  the 
habit  of  putting  pins  in  their  mouths  especially  when  dressing,  and  how 
many  workmen  jilace  small  foreign  bodies,  such  as  tacks  and  nails  and 
the  like  in  the  mouth.  C)f  course  in  infants  there  is  a  well  known  ten- 
dency to  put  everything  into  the  mouth,  as  this  seems  to  be  one  of  the 
means  by  which  the  infant  mind  acquires  knowledge  of  material  things. 
Soluble  material,  such  as  candy,  or  foods  which  very  quickly  disinte- 
grate, such  as  bread,  toast,  and  the  like,  need  cause  no  uneasiness,  as  they 
are  very  soon  coughed  up  and  expectorated.  Meat,  if  composed  purely 
of  muscular  fiber  or  fat,  is  practically  always  expectorated.  If,  however, 
it  is  firmlv  attaciied  to  periostium  or  bone  or  cartilage,  it  may  constitute 
a  foreign  body  for  which  bronchoscopy  should  be  done.  It  is  quite  re- 
markable that  all  strictly  food  substances  are  rather  rare  in  the  bronchi, 
while  the  portions  of  food  which  should  be  and  usually  are  rejected,  are 
not  at  all  uncommon,  such  as  the  seeds  of  fruits,  the  shell  of  nuts,  bone 
and  the  like.  ()f  course  it  is  not  nicmt  to  refer  here  to  the  various  food 
substances  such  as  dried  maize,  beans,  ])eas  and  the  like,  which  are  put 
into  the  mouth  by  children  in  play  and  not  strictly  for  food.  It  is  well 
known  that  any  light  particles  of  dust  usuallv  are  largely  removed  by 
the  cilia,  while  heavier  particles  of  dust  become  encysted  as  in  anthracosis. 
Just  where  the  border  line  exists  lietween  the  foreign  body  of  such  small 
size  that  it  ma_\-  become  encysted,  and  the  larger  bodies  which  will  form 
an  abscess,  has  never  been  determined,  and  it  is  very  difticult  to  determine 
because  the  smaller  bodies  which  form  an  abscess  usually  become  dis- 
integrated, or  are  lost  in  pus  and  are  never  discovered.  It  seems  quite 
certain  that  a  large  proportion  of  the  non-tuberculous  pulmonary  ab- 
scesses are  due  to  this  cause.  In  the  author's  collection,  pins  are  the  most 
frequent  of  foreign  bodies  in  the  bronchi.     Next  comes  various  forms  of 


238  Foreign  eudies  in  larynx  and  trachea. 

hardware,  and  then  various  vegetable  substances,  bones  and  coins.  Pea- 
nut kernels  are  among  the  most  fatal  of  foreign  bodies,  and  this  does  not 
seem  to  be  due  to  comminution  and  multiple  abscesses,  so  much  as  to  the 
peculiar  irritating  effect  of  the  peanut  kernel  upon  the  tracheo-bronchial 
mucosa.  A  metallic  body  will  be  tolerated  for  a  long  time  with  little  re- 
action, whereas  a  peanut  kernel  will  set  up  violent  local  reaction  in  a  few 
days  as  shown  by  the  author's  cases  to  be  cited  later.*  Dr.  E.  \V.  Car- 
penter (Bib.  73)  reports  the  case  of  an  infant  of  sixteen  months  that 
was  asphyxiated  by  the  pus  liberated  from  an  abscessed  lung  following 
the  aspiration  of  a  peanut.  J.  A.  Stucky  (Bib.  .Til)  and  many  others  re- 
port fatal  cases.  Metallic  bodies  if  of  such  shape  as  completely  to  occlude 
a  bronchus,  usually  cause  rapidly  developing  fatal  abscess  by  the  stagna- 
tion of  secretions  which  cannot  be  coughed  out.  On  the  other  hand  for- 
eign bodies  that  do  not  occlude  the  lumen  may  produce  little  reaction  for 
a  long  time,  provided  the  lumen  is  not  occluded  by  the  reactionary  swell- 
ing of  the  mucosa.  Sooner  or  later  this  occlusion  occurs,  however,  and 
the  patient  usually  succumbs.  Considering  the  millions  of  people  who 
are  carrying  about  with  them  loose  teeth  or  loose  artificial  dental  attach- 
ments it  is  a  very  remarkable  thing  that  relatively  so  few  foreign  bodies 
to  be  classed  as  dental  find  their  way  into  the  air  passages.  Large  arti- 
ficial dentures  are  bv  no  means  uncommon  in  the  esophagus  and  of 
course  by  reason  of  their  size  they  could  not  well  get  into  the  air  pas- 
sages. In  the  author's  opinion  it  is  a  great  tribute  to  the  skill  of  den- 
tists that  so  few  foreign  bodies  are  to  be  classed  as  dental.  Teeth  may 
be  knocked  loose  in  a  fall  and  be  aspirated  as  in  one  of  the  author's  cases. 
In  another  case  he  treated  laryngeal  stenosis  that  followed  an  abscess 
caused  by  impaction  of  a  tooth  in  the  subglottic  region.  The  rootless 
deciduous  tooth  had  shot  out  of  the  dental  forceps  in  the  hands  of  a 
skilful  dentist.  Dried  vegetable  substances  such  as  beans,  peas  and  maize 
soon  occlude  the  lumen  and  are  rapidly  fatal.  Those  interested  in  the 
further  pursuit  of  this  interesting  phase  of  the  foreign  body  question  are 
referred  to  the  excellent  article  of  D.  Bryson  Delavan  (Bib.  107)  which 
also  gives  a  number  of  references.  An  excellent  article  on  the  experi- 
mental pathology  of  foreign  bodies  in  the  lungs  was  written  bv  George  1'. 
Wood.   (I5ib.  .^85.) 

iriiy  do  forciijn  bodies  lodge  at  certain  localities  in  the  air  passages? 
Lodgment  at  some  of  the  most  fre(|uent  sites  is  accounted  for  by  seem- 
ingly adequate  reasons.  The  factors  may  be  classed  in  two  main  divis- 
ions: 

1.  (a)  The  size  and  shape  of  the  foreign  body:  whether  long, 
broad,  pointed,  angular,  disk-like,  etc.     (b  )   Its  surface,  whether  rough 

*So  uniformly  Is   this   olaserved  that   the   term  "peanut  bronchitis"   has   come 
into  rommon  use  in  the  author's  cUnic. 


FOREIGN    BODIES    IX    LAKV.W    AND   TKACIIF.A.  239 

or  smooth.  (2)  Its  physical  properties,  resiliency,  plasticity  absorptiv- 
ity, etc. 

2.  The  anatomic  peculiarities  of  the  various  localities,  (a)  Angles, 
arcs,     (b)  Fixed  and  motile  narrowings. 

The  size,  shape  and  surface  of  the  foreign  body  has  less  to  do  with 
the  particular  site  at  which  it  is  most  likely  to  lodge  than  have  the  anatom- 
ical regional  peculiarities.  A  pointed  body  may  catch  at  any  location 
if  the  point  be  downward  as  it  often  is  in  the  esophagus.  In  the  air 
passages,  however,  pins  are  almost  invariably  head  downward,  and  by 
a  ratchet-like  action,  the  point  preventing  return,  work  toward  the  low- 
est point.  In  the  air  passages  the  narrowness,  quiescent  and  spasmodic 
of  the  larynx  halts  many  foreign  bodies  which  may  be  retained  because 
of  peculiarities  of  their  shape,  or  by  a  projection;  or  by  entering  a 
ventricle.  As  in  one  of  the  author's  cases,  that  of  a  safety-pin,  one  part 
may  drop  through  the  glottis  while  another  part  not  passing  through,  the 
intruder  is  i)revented  from  going  either  way.  Having  passed  the  cords 
a  foreign  body  may  be  wedged  in  the  subglottic  space,  either  on  its  way 
down  or  when  it  is  shot  back  upward  by  the  bechic  blast.  Below  the 
subglottic  siKice  the  next  point  of  fre(iuent  lodgement  is  the  bifurcation. 
Lodgement  here  is  due  rather  to  the  shape  of  cross-section,  elongated 
laterally  witii  two  openings  laterally  below,  causing  the  intruder  to  be 
caught  crosswise.  More  often  it  is  the  etfort  of  the  intruder  to  enter 
either  the  right  or  the  left  bronchus,  both  of  which  are  smaller  than  the 
trachea.  The  bronchi  do  not  diminish  between  branches.  That  is,  the 
diminution  is  at  the  points  of  subdivision  ( monopodic  branching,  not 
true  bifurcations),  and  between  these  the  bronchus  is  cylindroid,  not 
tapered.  Therefore  a  foreign  body  usually  halts  with  its  largest  diam- 
eter at  or  immefliately  below  a  point  where  a  lateral  branch  is  given  off. 

Greater  frequency  of  riglit-broncliial  invasion.  The  right  bronchus 
is  invaded  by  foreign  bodies  more  frequently  than  the  left.  Statistics 
collected  by  Gottstein  show  that  7-"). 4  ])er  cent  of  foreign  bodies  entering 
the  bronchi  w'ere  in  the  right  bronchus.  \'on  Eicken  found  70.2  per  cent- 
Prcol>raschensky,  Oil  per  cent.  Morrell  Mackenzie,  02. .5.  The  reasons 
for  this  are  anatomical  and  physiological. 

1.  The  greater  diameter  of  the  right  bronchus. 

2.  Less  angle  of  deviation  of  the  right  bronchus. 

3.  Situatiiin  of  the  carina  to  the  left  of  the  long  axis  of  the  trachea. 

4.  The  action  of  the  trachealis  muscle. 

5.  The  greater  volume  of  air  going  into  the  riglit  broiicluis  on  in- 
spiration. 

The  first  three  of  these  factors  are  shown  in  the  schema  Fig.  1T1, 
The    riglit   bronchus    is   in   size   and    direction    the   continuation    of   the 


240 


I'OREIGN    BODIES    IN    AIR   AND   FOOD    PASSAGES. 


trachea ;  the  left  bronchus  in  many  cases  simulating  a  lateral  branch  of 
the  trachea  rather  than  a  bifurcational  half.  The  situation  of  the  carina 
to  the  left  of  the  long  axis  of  the  trachea  is  important.  Heller  and 
\'.  Schrotter  found  the  carina  to  the  left  in  57  per  cent,  in  the  middle 
line  in  -13  per  cent  and  to  the  right  in  1  per  cent.  Sir  Felix  Semon  and 
Morrell  Mackenzie's  joint  results  were:  left,  .59  per  cent,  middle  line. 
3.5  per  cent,  riglit,  il  per  cent.  These  statistics  are  all  based  on  the  cad- 
averic anatom)-.  The  author  feels  certain  that  the  living  anatomy  shows 
a  much  more  marked  preponderance  of  left-sided  situation  of  the  carina. 


Fig.  I/I.  Schema  showing  three  anatomical  reasons  for  the  greater  frequency 
of  right-sided  lodgement  of  foreign  bodies  in  the  bronchi.  The  right  bronchus 
(Rt.  B.)  is  almost  as  wide  (2.3  mm.)  as  the  trachea  (24  mm.)  and  it  deviates  much 
less  than  the  left  from  the  long  axis  of  the  trachea.  The  carina,  C,  is  to  the  left 
of  this  axis,     (.\fter  Sir  St.  Clair  Thomson.) 


He  regrets  that  he  did  not  keep  a  record  of  this  point  in  all  of  his  bron- 
choscopic  cases.  But  in  40  cases  where  he  kept  a  record  the  carina 
seemed  more  or  less  to  the  left  in  all  but  one  and  in  that  case  the  carina 
seemed  central.  These  cases  were,  without  known  pathology  that  could 
alter  the  position  of  the  carina.  The  observation  is  submitted  with  ac- 
knowledgment of  the  possibility  of  error,  because  of  the  alteration  of 
position  of  all  the  thoracic  viscera  due  to  position  of  the  patient,  the 
bronchoscopic  tube  and  the  pulsatorv  and  resjiiratory  movements.  Fur- 
thermore, the  observations  were  incidental  antl  no  time  was  taken  to  in- 


FOREIGN  BODIKS  IN  AIR  AND  FOOD  PASSAGES.  241 

sure  accurac}'.  From  j^eneral  observation  and  the  instinctive  habits  of 
work,  the  aiitlior  has  come  always  to  move  the  head  to  the  right  to  get 
into  the  left  bronchus  while  the  head  is  not  moved  to  the  left  simply  to 
cause  the  bronchoscope  to  enter  the  right  bronchus.  It  always  goes 
there  naturally  with  the  head  in  the  middle  line,  though,  of  course,  the 
author's  custom  of  turning  the  lip  of  the  bronchoscope  to  the  right  for 
entering  the  right  bronchus  assists.  The  action  of  the  musculature  at 
the  carina  in  drawing  the  carina  to  the  left  and  thus  reducing  the  size 
of  the  left  bronchial  orifice  is  thought  by  Snow  to  be  one  of  the  chief 
factors  in  the  preponderance  of  foreign  bodies  in  the  right  bronchus. 
The  fifth  factor  mentioned  above  does  not  seem  to  have  received  the 
attention  it  deserves.  In  one  of  the  author's  cases,  that  of  an  extremely 
dyspneic  child,  there  was  demonstrated  by  physical  examination  by 
Dr.  H.  T.  Price  very  little  air  going  into  the  right  side  and  none  at  all 
into  the  left.  The  foreign  body  was  in  the  subglottic  space.  This  case 
seems  to  pro\e  what  theoreticallv  would  seem  probable  from  the  greater 
size  of  the  right  lung,  that  there  is  a  greater  volume  of  air  rushing 
through  the  right  bronchus  at  each  inspiration. 

Why  is  the  middle  lobe  bronchus  rclatiiely  so  rarely  invaded  by 
foreign  bodies?  The  middle  lobe  bronchus  is  rarely  invaded.  The 
author  has  seen  but  two  such  instances,  in  over  two  hundred  cases  of 
foreign  body  in  the  bronchi.  The  relative  rarity  of  invasion  possibly  is 
due  to  the  fact  that  the  middle  lobe  bronchus  is  given  off  anteriorly^ 
consequently  gravity  tends  to  lead  the  foreign  body  into  posterior 
branches  because  the  patient  docs  not  lie  on  his  face  but  on  his  back. 
This  theory  of  the  author  has  never  been  positively  proven  because  for- 
eign bodies  are  rarely  radiographed  soon  enough  after  the  accident,  i.  e., 
before  the  patient  has  lain  down.  Excluding  the  effect  of  gravity,  the 
angle  of  the  giving  off  the  middle  lobe  bronchus  does  not  seem  less 
favorable  for  the  invasion  by  a  foreign  body  than  do  some  of  the  dorsal 
branches  of  the  inferior  lobe  bronchus  which  are  so  fre(|uently  invaded. 
True,  in  looking  down  the  lumen  of  the  rigiit  stem  bronchus  the  orifice 
of  tlie  middle  lobe  iironcluis  is  not  seen,  which  would  lead  one  to  think 
that  it  is  out  of  the  direct  route  of  the  invader.  To  some  extent,  how- 
ever, this  is  also  true  of  the  dorsal  branches  of  the  inferior  lobe  bron- 
chus. The  inspiratory  air  blast  eiUering  the  middle  lobe  iironchus  pos- 
sibly is  not  (|uitc  so  great.  It  is  hoped  that  future  observation  will  clear 
up  this  point.  William  llruce  Smith  reiJorts  an  interesting  case  of  mid- 
dle lobe  brnnrluis  invasion. 

Spontaneous  expulsion  of  foreign  bodies  from  the  trachea  and 
bronchi.  Fortunately  for  the  patient,  but  unfortunately  for  other  pa- 
tients, foreign  bodies  are  occasionally  coughed  u[>.     Still  more  unfortu- 


242  FOREIGN  BODIES  IN  LARYNX  AND  TRACHEA. 

nate  is  the  fact  that  no  distinction  ordinarily  is  made  between  a  foreign 
body  coughed  out  of  the  lar\'nx  and  the  much  rarer  event  of  one  coughed 
up  from  the  bronchi.  It  is  for  the  latter  reason  that  statistics  are  al- 
most valueless.  There  have  been  too  few  cases  of  spontaneous  expul- 
sion where  the  location  of  the  intruder  was  precisely  known.  Man- 
ifestly the  expulsion  of  a  large,  light  foreign  body  in  the  larynx  or  sub- 
glottic trachea  is  no  basis  for  deduction  as  to  a  specifically  heavy  foreign 
body  in  a  minute  bronchial  branch  at  the  periphery  of  the  lung.  In 
these  days  of  safe  and  easy  bronchoscopy  with  an  enormous  percentage 
of  .successes,  no  one,  who  is  well  informed,  for  one  moment  considers 
the  advisability  of  waiting  for  a  foreign  body  to  be  coughed  up ;  but  in 
the  event  of  bronchoscopy  failing  to  remove  the  intruder,  the  very  high 
mortality  of  thoracotomy  for  foreign  body,  together  with  a  certain  per- 
centage of  failures  to  find  the  intruder  by  external  operation ;  and, 
furthermore,  as  there  may  be  present  at  consultation  someone  who  will 
recite  a  case  where  the  foreign  body  was  coughed  up — for  these  reasons, 
it  is  wise  to  consider  the  possibilities.  The  chance  of  the  bechic 
expulsion  of  a  foreign  body  depends  largely  on  its  nature.  Sharp  for- 
eign bodies,  such  as  pins  lying  point  upward,  have  never  been  known 
to  be  coughed  up,  for  the  reason  that  the  pin  will  stick  at  the  very  first 
angle  encountered.  On  the  other  hand,  smooth,  rounded  bodies  have  a 
tendency  to  be  tightly  fixed  in  the  bronchus,  and  the  absorption  of  air 
below  causes  a  negative  pressure  which  pulls  the  foreign  body  tighter 
and  tighter  into  the  bronchus  with  less  and  less  air  below,  and  conse- 
quently less  and  less  chance  for  expulsion.  The  patient  cannot  draw 
in  air  enough  beneath  the  foreign  body  for  the  expulsive  efforts.  In 
the  third  class  might  be  considered  the  foreign  bodies  that  are  quite 
heavy,  such  as  bodies  of  iron,  pewter,  lead,  and  the  like.  These  are 
very  rarely  ever  coughed  out  because  of  the  little  surface  they  present 
relatively  to  their  weight.  The  expiratory  blast  has  not  sufficient  force, 
relatively  to  the  surface  against  which  the  force  is  applied,  to  expel  the 
intruder.  We  come  then  to  the  class  of  foreign  bodies  which  are  not 
hca\y  nor  sharp-pointed  nor  so  smooth  as  to  lodge  tightly,  thus  pre- 
venting air  from  being  drawn  below  them,  and  we  find  such  bodies  are 
the  most  likely  to  be  expelled.  The  chances  are  better  before  than  after 
such  a  body  has  reached  the  smallest  bronchus  it  can  enter.  It  is  not 
so  tightly  impacted  at  first  unless  its  size  is  so  large  as  to  nearly  oc- 
clude the  trachea  or  bronchi.  In  that  case  it  is  draw-n  in  by  the  in- 
spiratory blast  and  accumulates  energy  on  the  way  according  to  the  well 
known  law  of  physics.  This  accumulation  is  less,  directly  as  the  actual 
weight,  and  also  as  the  specific  weight,  except  in  cases  of  foreign  todies 
which  fit   quite  closely   to   the   tracheal   or  bronchial   lumen.      This   ac- 


FOREIGN    BODIES    IN    LARYNX    AND  TRACHEA.  843 

cumulated  energy  in  travel  cannot  occur  in  expulsion  until  after  impac- 
tion is  released,  because  it  does  not  l)csi;in  until  the  body  bas  begun  to 
move.  Hence  there  is  a  great  disadvantage  in  expulsion  as  compared  to 
inhalation  of  a  foreign  body.  This  is  not  sufiicient  to  overcome  the 
relative  advantage  which  should  accrue  from  the  fact  that  an  exjjulsive 
effort  in  coughing  is  very  much  greater  in  jiower  than  any  inspiratory 
effort  can  be,  the  difference  being  probably  twice  as  much  in  a  coughing 
expiratory  pressure.  Then  we  have  the  absorption  of  air  drawing  the 
foreign  body  downward  in  the  case  of  round  foreign  bodies  which  fit 
the  bronchial  lumen,  either  at  first  or  after  swelling  has  taken  place. 
This  accounts  for  the  fact  that  corks  and  similar  substances,  though  of 
low  specific  weight,  are  rarely  coughed  up.  Pins  almost  invariably  enter 
the  air  passages  point  upward  and  the  point  constitutes  a  ratchet-like 
mechanism  which  resists  any  other  movement  than  downward ;  and 
moreover,  the  pin  offers  but  little  surface  upon  which  the  expiratory 
blast  in  coughing  may  act.  Furthermore,  to  get  out  at  all,  it  must  pro- 
ceed with  its  long  axis  more  or  less  in  the  axis  of  the  passage  through 
which  it  must  go.  .Anyone  who  will  attempt  to  throw  any  sort  of  a  pin 
])oint  first,  will  find  that  the  head  of  the  pin,  being  heavier,  very 
promptly  begins  to  turn  round  in  advance  of  the  point.  With  prac- 
tically all  i)ins  this  would  be  impossible  in  expulsion  through  the  air 
passages  for  want  of  S])ace,  and  the  turning  would  cause  the  point  to 
stick  even  if  the  passage  were  straight.  On  the  contrary,  a  number  of 
bends  and  turns  have  to  be  accomplished.  l'"or  tiiese  reasons,  a  pin 
that  has  gotten  down  to  the  bifurcation  or  below,  practically  never  is 
coughed  up,  and  if  it  is  in  the  trachea  it  is  almost  certain  to  reach  the 
deeper  air  passages  in  a  very  short  time  by  the  combined  action  of  grav- 
ity and  the  ratchet-like  action  of  the  ])oint.  Another  factor  against  the 
coughing  up  of  a  foreign  body  is  that  of  gravity.  This  led  in  the  pre- 
bronchoscopic  days  to  the  holding  up  of  the  patient  by  the  heels  in  order 
to  let  the  foreign  body  fall  out.  This  was  occasionally  successful  within 
a  few  days  of  the  accident,  though  it  sometimes  caused  a  spasm  of  the 
glottis  and  demanded  immediate  tracheotomy.  ( )f  course  such  a  pro- 
cedure is  not  to  be  considered  in  these  days  of  bronchoscopy ;  but  the  fact 
that  it  sometimes  succeeded  indicates  the  efl'ect  that  gravity  has  in  in- 
terfering with  the  coughing  out  of  foreign  bodies.  As  elsewhere  men- 
tioned, the  dog  has  a  vastly  more  effective  mechanism  for  ridding  his 
bronchi  of  foreign  bodies  than  is  possessed  bv  human  beings.  To  what 
extent  the  more  nearly  iiorizontal  trachea  and  bronchi  of  the  dog  is  con- 
cerned, has  not  yet  been  determined.  It  sccnis  prol)ablc.  however,  that 
the  erect  posture  of  human  beings,  which  is,  phylogeneticaliv,  verv  late, 
is  in  a  measure  responsible  for  the  very  inefiicient  efforts  of  nature  to 


3-14  FOREIGN  BODIES  IX  LARYXX  AND  TRACHEA. 

cough  out  foreign  bodies.  Another  factor  which  favors  the  inhalation 
of  a  foreign  body  and  retards  its  expulsion  is  the  well  known  physiological 
action  of  the  glottis.  During  inspiration  the  glottic  chink  is  widened 
to  the  maximum,  while  on  expiration  it  is  only  partially  open  and  it  does 
not  open  to  the  maximum  even  during  the  expulsive  efforts  of  the  cough. 
Moreover,  the  foreign  body  itself,  being  driven  up  against  the  under 
side  of  the  vocal  cords,  or  even  against  the  tracheal  wall,  has  a  strong 
influence  in  exciting  reflex  contraction  which  closes  the  glottis.  Still 
another  impediment  to  the  expulsi\e  efforts  of  the  cough  is  the  fact 
that  the  bronchi  contract  very  greatly  during  cough  and  the  trachea 
also  contracts  to  a  certain  extent.  This  contraction  has  been  witnessed 
by  every  bronchoscopist,  as  it  is  one  of  the  difficulties  with  which  he 
has  to  contend  in  bronchoscopy.  Perhaps  one  of  the  most  important 
factors  in  the  defeat  of  the  bechic  expulsion  of  foreign  bodies  is  the 
fact  that  after  each  coughing  effort  there  is  a  deep  inspiration,  during 
which  the  bronchi  are  dilated  and  the  inspiratory  blast  has  the  effect  of 
carrying  the  foreign  body  deeper  and  deeper,  aided  by  the  negative 
pressure  below. 

In  deciding  the  chance  of  spontaneous  expectoration  of  a  foreign 
body  in  the  bronchi  it  is  necessary  to  remember  the  very  inefficient 
coughing  and  expectorating  mechanism  of  children. 

Summarizing,  we  divide  for  prognostic  purposes  all  foreign  bodies 
into  three  classes : 

1.  Those  of  high  specific  gravity. 

2.  Those  of  low  specific  gravity,  (  including  hollow  bodies  with 
relatively  large  surface). 

3.  Those  of  intermediate  suecific  gra\ity. 

In  the  first  class  we  may  tell  our  patient  that  there  is  almost  no 
hope  of  the  intruder  ever  being  coughed  up  in  case  of  adults  and  ab- 
solutely none  in  infants  and  very  small  children.  In  the  second  class 
there  is  a  chance  of  expectoration  in  older  children  and  adults,  almost 
none  in  children,  none  at  all  in  infants.  In  the  third  class  of  substances 
the  chances  of  expectoration  of  the  foreign  body  in  either  adults  or 
children  are  remote.  Long,  thin,  pointed  and  relatively  heavy  bodies 
like  pins  and  needles  are  never  coughed  up  from  below  the  glottis.  In 
any  case,  the  author's  later  experience  confirms  his  earlier  statement 
(Bib.  2(59)  :  namely,  "We  do  full  justice  to  our  patients  when  we  tell 
them  that  while  the  foreign  body  may  be  coughed  up.  it  is  verv  danger- 
ous to  wait;  and.  further,  that  the  difficulty  of  removal  increases  with 
each  hour  the  body  is  allowed  to  remain." 

Magnetic  extraction  of  foreign  bodies.  Many  of  the  mechanical 
problems,  and  also  the  problem  in  certain  cases  of  finding  the   foreign 


FOREIGN  HODIKS  IN   I.XKVNX  AND  TRACHKA.  2-t5 

body,  would  be  solved  if  magnetic  extraction  were  feasible.  It  bas 
yielded  such  wonderful  results  in  oiilithalmology  tbat  its  use  in  bron- 
choscopy at  least  seemed  worthy  of  development.  Ten  years  ago  the 
author  experimented  quite  thoroughly  and  the  results  of  the  experiments 
were  published  in  The  Laryngoscope  (Bib.  233).  Only  four  of  the 
conclusions  need  be  mentioned  here,  namely : 

1.  The  foreign  body  must  be  of  iron  or  steel,  partly  or  wholly. 

2.  The  body  must  be  free  to  move. 

3.  The  attraction  of  the  magnet  for  the  foreign  body  is  no  greater 
than  that  of  the  foreign  body  for  the  magnet,  hence  : 

4.  The  probabilities  of  magnetic  removal  are  directly  as  the  size  of 
the  foreign  body,  within  the  limits  of  size  i)ermitting  mobility. 

It  will  be  seen  by  the  foregoing  that  the  magnet  is  only  useful  in 
precisely  those  cases  which  are  most  favorable  for  bronchoscopic  meth- 
ods. Unfortunately  magnetic  extraction  does  not  assist  in  those  cases 
beyond  the  limits  of  bronchoscopy.  R.  C.  Lynch  (Bib.  3.50)  reports  a 
successful  case  of  magnetic  extraction,  as  does  also  Iglauer  (Bib.  221). 

Mortality  and  results  of  bronchoscopy  for  foreign  bodies:  In  con- 
sidering the  mortality  of  bronchoscopy,  two  facts  stand  out  prominently. 
The  first  is  that  we  should  distinguish  between  the  mortality  of  the 
method  on  the  one  hand,  and  the  mortality  from  the  lack  of  prompt- 
ness and  precision  in  performing  it.  For  instance,  the  reports  of  four  of 
the  fatal  cases  show  that  the  patients  died  upon  the  table  of  asphyxia 
for  want  of  a  prompt  bronchoscopy. 

Ingals,  who  is  a  pioneer  bronchoscopist  of  large  experience,  writes : 
"Owing  to  numerous  cases  that  come  to  my  knowledge  where  inexper- 
ienced men  have  performed  bronchoscopy  with  fatal  results,  and  owing 
also  to  my  recollection  of  the  difficulties  I  experienced  in  the  beginning 
of  this  work,  I  think  it  is  highly  desirable  that  some  statement  be  made 
which  would  deter  the  inexperienced  from  undertaking  these  operations 
needlessly.  I  believe  the  fatalities  witii  inexperienced  people  would  run 
between  Id  and  20  per  cent  if  all  cases  could  be  collected." 

\'on  Eicken  collected  300  cases  of  bronchoscopy  for  foreign  bodies 
up  to  and  including  the  year  litOS.  The  total  mortality  from  all  causes 
is  given  as  13.1  per  cent.  His  statistics  show  for  the  [)re-bronclio- 
scopic  period,  'rZ  per  cent.  This  brought  into  strong  contrast  the  won- 
derful results  of  bronchoscopy  even  in  the  hands  of  beginners,  as  many 
of  the  cases  were,  and  is  a  tribute  to  Killian,  the  father  of  bronchoscopy. 
The  statistics  of  li'oii  and  litio  were  collected  by  Kahler,  consisting  of 
2!)1  cases  with  a  mortalitv  of  27.  making  li.(i  |)er  cent.  Of  this  mortal- 
ity, not  a  single  case  could  be  attributed  directly  to  bronchoscopy,  but 
rather  to  the  results  of  the  foreign  body  itself  or  of  blind  methods  of 


24G  FOREIGN    BODIES    IN    LARYNX    AND   TRACHEA. 

removal  attempted  prior  to  the  bronchoscopy.  The  statistics  of  these 
two  years,  as  compared  with  those  collected  by  Kahler  of  the  time  prior 
to  1909,  show  clearly  the  improvement  in  technic  and  instruments,  as  well 
as  in  the  personal  skill  of  the  various  operators.  As  Briinings  points 
out,  if  it  is  desired  to  get  at  the  exact  mortality  of  bronchoscopy  per  se, 
it  will  be  necessary  to  include  in  statistics  only  the  cases  in  which  the 
foreign  body  has  not  been  long  present,  because  of  the  secondary  changes 
that  take  place  after  a  more  or  less  prolonged  sojourn  of  the  foreign 
body.  In  preparing  a  "Rapport"  for  the  International  Medical  Congress 
(Bib.  270),  the  author  collected  171  cases  of  bronchoscopy  for  foreign 
bodies  done  in  the  United  States  ( European  statistics  being  in  charge 
of  the  co-rapporteur,  Prof.  Killian)  by  \arious  operators.  In  the  171 
cases  there  were  nine  deaths  (.5.3  per  cent  J.  This  does  not  include  four 
deaths  due  to  asphyxia  for  want  of  promptness  in  performing  bron- 
choscopy. Of  these,  lot!  were  removed,  14U  by  peroral  bronchoscopy, 
23  by  tracheotomic  bronchoscopy.  Of  the  fifteen  unsuccessful  cases, 
twelve  were  failures  to  find  the  foreign  body  known  to  be  present,  and 
only  three  were  failures  to  remove  it  when  found.  In  the  twelve  cases 
mentioned  as  failures  to  find  the  foreign  body  are  included  four  in 
which  the  foreign  body  had  been  seen  when  higher  up.  After  escaping 
into  the  deeper,  minute  bronchi  it  could  not  be  re-located  bronchoscop- 
ically,  though  still  showing  in  the  radiograph.  The  statistics  of  the 
author's  own  clinic  and  of  his  cases  elsewhere,  which  are  not  included 
in  the  foregoing,  are  as  follows :  Of  the  last  182  consecutive  cases  of 
bronchoscopy  for  foreign  body  there  was  a  total  of  three  deaths  (1.7 
per  cent)  from  any  cause  whatever  within  one  month,  though  a  few  of 
the  cases  could  not  be  followed  this  long.  Of  the  183  cases  all  were 
peroral  bronchoscopies.  Of  the  182  cases,  the  foreign  body  was  removed 
in  177.  Of  the  five  failures  to  remove  foreign  bodies  known  to  be 
present,  all  were  failures  to  find  a  small  foreign  body  that  was  in  a  small 
branch  bronchus  close  to  the  periphery  of  the  lung.  Two  of  these  cases 
were  recent.  The  percentage  of  the  author's  failures  will  doubtless  in- 
crease in  the  future,  since  he  now  gets  the  cases  upon  which  others  have 
been  unsuccesful  and  doubtless  he  will  be  equally  so ;  though  he  has 
hopes  that  the  elsewhere  mentioned  recently  perfected  means  of  locating 
small  bodies  in  small  bronchi  near  the  periphery  will  diminish  for  every 
one  the  number  of  cases  in  which  the  intruder  cannot  be  found. 

Indications  for  bronchoscopy  in  suspected  foreign  body  cases.  It 
would  be  a  mistake  to  elaborate  many  fine  points  of  distinction  as  to  the 
indications  for  bronchoscopy  in  suspected  foreign  body  cases  for  -three 
reasons:  (a)  A  foreign  body  ma\'  be  present  without  any  demonstrable 
signs  or  symptoms,      (b)    In  all  cases  of  doubt  a  bronchoscopy  should 


FORKICN  r.ODir.S  IX  LAKVNX  AM)  1RACHKA.  247 

be  done  anyway,  (c)  Disease  may  be  found  to  account  for  foreign 
body  symptoms.  The  first  two  reasons  are  so  abundantly  proven  as  to 
need  no  citation  of  cases.  The  third  reason  (c)  may  be  supported  by 
two  cases  selected  from  among  a  number  because  the  bronchoscopic 
diagnosis  was  of  fundamental  therapeutic  importance.  A  man  of  forty 
years  was  referred  to  the  author  for  removal  of  a  wooden  toothpick 
which  was  thought  by  the  patient  to  be  the  cause  of  a  cough  of  sudden 
on.set  following  "cjioking  on  a  toothpick."  No  foreign  body  was  found 
but  an  indurated  ulcer  at  the  carina  lead  to  a  diagnosis  of  lues  which 
was  verified  later.  Mr.  H.  J.  Davis  reports  an  interesting  case  in  which 
a  fourteen-year-old  child  insisted  that  she  could  feel  a  pin  in  her  chest. 
The  radiograph  was  negati\e  but  on  passing  the  bronchoscope  he  found 
a  diphtheritic  membrane  in  the  trachea  though  none  was  present  higher 
up. 

Acute  disease,  such  as  the  bronchopneumonia  of  children  and  unex- 
plained "edema  of  the  lungs,"  may  in  a  few  cases  suspected  of  foreign 
body  origin  be  indications  for  bronchoscopy. 

The  simulation  of  tuberculosis,  chronic  pleurisy  with  effusion,  bron- 
chitis, asthma,  bronchiectasis  and  other  chronic  lung  affections  by  pro- 
longed sojourn  of  a  foreign  budy  renders  bronchoscopy  indicated  in  cer- 
tain cases  of  these  diseases.  Instances  have  been  reported  by  the  author 
and  others  where  these  diseases  have  actually  arisen  secondarily  to  the 
presence  of  a  foreign  body.  Of  course  it  is  not  meant  to  urge  bron- 
choscopy for  foreign  bodies  in  all  cases  of  the  diseases  mentioned  except 
bronchiectasis ;  but  bronchoscopy  is  indicated  in  any  case  where  there  is 
a  possibility  of  foreign  body  origin  and  in  certain  cases  it  is  indicated  for 
assistance  in  diagnosis  and  treatment  of  the  diseases  independently  of  a 
foreign  body  element.  A  radiograph  may  confirm  or  negative  the  indica- 
tion. This  matter  is  more  fully  considered  in  connection  with  the  prob- 
lems presented  by  bronchial  foreign  body  cases  of  prolonged  sojourn. 
The  various  indications  for  bronchoscopy  in  suspected  foreign  body  cases 
may  be  summed  up  as  follows,  though  this  is  by  no  means  a  complete 
category : 

1.  The  appearance,  in  the  radiogra])h,  of  a  foreign  body  or  of  any 
suspicious  shadow. 

2.  In  any  case  in  which  there  is  a  clear  history  of  the  patient  hav- 
ing choked  on  a  foreign  body,  and  in  wliicii  the  foreign  body  was  not 
afterwards  found. 

In  this  coimection,  it  must  be  borne  in  mind  tiial  f(jreign  bodies 
ma\  be  nuiitiple,  as  in  one  case  of  the  author,  in  which  a  bronchoscopy 
was  not  done  because  after  the  accident  a  gourd  seed  was  found  in  the 


248  FORKIGN  r.ODIK.S  IN  I.ARVNX  AND  TRACIIKA. 

Stools.     I'hree  months  later  he  removed  a  gourd  seed  from  the  bronchus. 
The  child  had  been  playing  with  a  whole  mouthful  of  gourd  seeds. 

3.  In  any  case  in  which  there  are  signs  of  stenosis  of  the  trachea 
or  of  a  bronchus. 

4.  Any  case  suspected  of  bronchiectasis. 

5.  In  the  absence  of  anv  foreign  body  history,  the  patient  giving 
symptoms  of  pulmonary  tuberculosis,  in  which  the  bacilli  cannot  be  found 
in  the  sputum  and  especially  if  the  physical  signs  are  at  the  base,  par- 
ticularly the  right  base,  and  above  all,  if  there  are  also  physical  signs  of 
pleural  effusion. 

(i.      In  case  of  doubt,  bronchoscopy  should  be  done  anyway. 

Contra-indications  to  bronchoscopy  for  foreign  bodies.  The  author 
has  had  no  cause  to  modify  his  views  previously  expressed  (Bib.  269), 
namely,  that  there  is  no  absolute  contra-indication  to  bronchoscopy. 
In  some  cases  of  extreme  exhaustion,  for  instance  when  a  patient  who 
has  already  had  too  many  bronchoscopies,  it  may  be  advisable  to  delay 
until  the  patient  recuperates.  Pneumonia  of  any  form  is  certainly  no 
contra-indication.  It  has  been  the  author's  custom  to  remove  the  foreign 
body  even  at  the  height  of  pneumonia,  and  invariabh-  the  influence  of  the 
removal  of  the  foreign  body  has  been  good,  rather  than  otherwise.  Pul- 
monary abscess  and  other  local  lesions  due  to  the  presence  of  the  foreign 
body  itself,  far  from  being  contra-indications,  are  indications  of  the 
strongest  kind  for  immediate  bronchoscopic  removal  of  the  intruder. 
Gangrene  of  the  lung  is  not  a  contra-indication  to  bronchoscopic  removal 
of  a  foreign  body  unless  the  patient  is  moribtmd.  Gtiisez  has  success- 
fullv  treated  gangrene  of  the  lung  bronchoscopically.  It  goes  withottt 
saying  that  if  the  patient  is  dying  from  obstruction  due  to  the  foreign 
body,  an  immediate  bronchoscopy  is  indicated;  but  if  the  patient  is  mori- 
bund from  other  causes,  bronchoscopy  is  contra-indicated  until  the  pa- 
tient has  rallied.  Serious  organic  disease,  such  as  aneurysm,  does  not 
constitute  an  absolute  contra-indication,  for  unless  the  patient's  immedi- 
ate condition  is  serious  from  the  aneurysm,  he  will  live  longer  with  the 
foreign  body  out  than  in.  The  author  has  had  three  foreign  body  cases 
in  each  of  which  a  diagnosis  of  the  vague  syndrome  called  "status  lym- 
phaticus"  had  been  made  by  a  competent  internist,  and  yet  nothing  vm- 
usual  was  noticed  at  the  bronchoscopy,  nor  afterward.  In  a  number 
of  other  foreign  body  cases  a  slight  degree  of  thymic  compression  was 
noted  incidentally  at  bronchoscopy.  Xo  anesthetic  was  used  in  any  of 
these  cases.  The  author  quite  agrees  with  Clark  that  "status  lymphat- 
icus"  is  no  contra-indication.  When  a  patient  is  in  bad  general  condi- 
tion, but  not  dyspneic,  the  question  arises  whether  it  is  wise  to  wait  for 
the  patient  to   recuperate  before   doing  the   bronchoscopv   for  removal. 


FORKICN  BODIES  IN  LARYNX  AND  TRACHKA.  349 

Tlic  situation  is  best  illustraleil  by  tbe  following  case:  Three  days  after 
having  aspirated  a  pin,  an  infant  was  sent  from  a  distant  city  where  it 
iiad  been  subjected  to  an  oral  bronchoscopy  of  one  hour's  duration,  fol- 
lowed Ijv  a  tracheotiimy  and  a  tracheotomic  bronchoscopy  of  two  hours' 
duration  on  the  day  after  having  aspirated  the  pin,  involving  an  ether 
anesthesia  of  one  hour's  duration  the  first  day  and  of  two  hours'  duration 
the  second  day.  Then  it  was  subjected  to  a  day's  travel.  W  hen  the 
child  arrived  it  was  ijuite  e.\hausted  from  the  various  ordeals  and  the 
interference  with  regular  nutrition.  The  question  arose  whether  under 
these  circumstances  it  were  better  to  do  the  bronchoscopy  at  once  or 
to  wait  for  recuperation.  The  only  objection  to  waiting  was  that  the 
difficulty  of  removal  usually  increases  steadily  with  each  day  that  elap.ses 
after  the  inspiration  of  a  \'ery  minute  foreign  body  into  a  very  small 
bronchus.  For  this  reason,  immediate  bronchoscopy  was  decided  upon 
and  successfully  executed  through  the  mouth.  There  was  no  increase 
in  the  exhaustion  and  the  child  rallied  well  and  was  sent  home  a  few 
days  later.  Had  the  foreign  body  been  of  larger  size,  instead  of  in  a 
small  broncinis  which  could  have  easily  swollen  shut  by  a  few  days 
longer  wait,  the  author  and  his  medical  advisors  would  have  decided  on 
waiting  for  the  child  to  rallv  before  subjecting  it  to  any  further  ordeal 
Fortunately,  we  were  able  to  do  the  work  without  anesthesia.  J  lad  a 
general  anesthetic  been  retjuired,  it  doubtless  would  have  involved  very 
great  risk  in  the  exhausted  condition  of  the  child.  Had  dyspnea  been 
present,  of  course  immediate  bronchoscopy  would  have  been  obligatory 
and  no  (|uestion  of  delay  could  have  been  considered  for  one  moment.  In 
view  of  such  experiences  as  these,  tbe  author  feels  that  the  (|ueslion 
should  be  decided  on  the  following  basis:  In  cases  without  dyspnea, 
where  a  large  foreign  body  is  present  in  a  child  very  much  exhausted 
from  any  cause,  it  is  better  to  wail,  under  careful  watching,  for  recu()era- 
tion  :  and  if  general  anesthesia  is  to  be  used,  it  is  quite  imperative  to 
wait.  If.  on  the  other  hand,  the  foreign  body  is  of  the  nature  of  a  small 
pin  or  needle  that  has  invaded  a  very  small  bronchus  far  out  toward 
the  jjeriphery  of  the  lung,  it  is  better  to  proceed  at  once  without  any  an- 
esthesia, general  or  local.  If  there  is  dyspnea  present,  immediate  bron- 
choscopy is  absolutely  imperative,  and  it  must  be  done,  without  anv  an- 
esthesia, general  or  local.  We  are,  of  course,  speaking  of  children  only: 
in  adults  there  would  be  little  or  no  danger  in  the  use  of  a  local  anes- 
thetic. In  ]iassing,  it  may  be  mentioned  that  in  cases  such  as  the  one 
cited  above,  the  inefficiency  of  the  infantile  cough  in  the  remoxal  of  se- 
cretions must  be  borne  in  mind  as  mentioned  under  "Drowning  of  the 
patient  in  his  own  secretions." 


250  FOREIGN   BODIES   IN    LARYNX    AND  TRACHEA. 

Choice  of  time  to  do  bronchoscopy  for  a  foreign  body.  The  choice 
of  time  to  operate  is  as  soon  as  possible  after  the  accident.  The  difficul- 
ties of  removal  increase  steadily  from  that  time  onward.  The  bronchi 
will  swell  shut  and  the  orifices  will  be  entirely  obliterated  temporarily 
by  edema,  later  by  the  organization  of  granulation  tissue,  or  the  granula- 
tion tissue  will,  by  its  bleeding,  render  much  more  difficult  the  bronchos- 
copic  removal,  or  the  secondary  changes,  such  as  strictures,  will  enor- 
mously increase  the  difficulties.  The  patient's  health  will  deteriorate, 
making  him  a  less  favorable  subject  for  bronchoscopy,  and  occasionally 
the  foreign  body  may  escape  from  the  bronchus  into  the  tissues,  though 
this  is  a  rare  accident.  In  case  of  bodies  liable  to  exj)and  or  become 
friable  by  absorption  of  moisture,  as  dried  beans,  peas,  maize  and  the 
like,  every  moment  lost  decreases  the  patient's  chances.  This  does  not 
justify  hasty  or  ill-planned  efforts  without  equipment ;  but,  as  Emil 
Ma\er  says,  "Such  a  patient  should  be  looked  upon  as  constituting  an 
emergency  case  to  be  operated  upon  at  once."  Solid  bodies  that  by 
their  shape  are  apt  to  occlude  a  bronchus,  even  though  they  do  not 
swell,  are  to  be  operated  upon  at  once,  also,  because  of  the  serious  effect 
of  atelectasis  and  stagnation  of  secretion  below  the  intruder,  and,  most 
important  of  all,  because  of  the  drawing  downward  of  the  foreign  body 
by  negative  pressure  which,  with  the  swelling  of  the  mucosa  above  as 
shown  in  Fig.  182,  makes  removal  more  and  more  difficult  the  longer 
the  delay. 

The  duration  of  a  bronchoscopy.  Endoscopists  are  now  agreed  that 
prolonged  bronchoscopy  in  children  is  inadvisable  and  that  a  number  of 
shorter  sittings  is  safer.  This  has  no  reference  to  the  ques- 
tion of  subglottic  edema  which  will  be  sei)arately  considered.  The 
author  has  frequently  prolonged  bronchoscopy  to  one  hour's  duration  in 
children ;  but  as  a  rule,  a  half  hour  from  the  time  the  bronchoscope 
passes  through  the  larynx,  should  be  the  limit  except  in  exceptional  in- 
stances, in  a  child  under  two  years  of  age.  Over  two  years  of  age,  a 
bronchoscopy  of  an  hour,  without  anesthesia,  general  or  local,  is  prac- 
tically without  risk.  Drug  shock,  especially  the  paralyzing  effect  mor- 
phine and  chloroform  have  on  the  respiratory  center,  renders  a  bronchos- 
copy of  over  fifteen  minutes'  duration  hazardous.  In  an  adult,  the  author 
has,  in  one  instance,  prolonged  the  bronchoscopy  to  three  and  a  half 
hours,  using  a  very  little  bit  of  cocaine  solution  a  number  of  times,  ap- 
plied only  to  the  neighborhood  of  a  foreign  body  in  the  bronchus. 

This  matter  of  duration  is  so  important,  and  is  so  greatly  influenced 
by  various  factors,  that  it  is  quite  necessary  for  bronchoscopists  to  re- 
cord the  duration  of  their  endoscopies  in  order  to  get  data  for  a  work- 
ing basis.     The  author  has  such  a  record  for  most  of  his  cases. 


I'ORKICX  BODIHS  IX  I.ARVNX  AND  TRACHEA.  251 

The  endoscopic  appearances  of  foreign  bodies  in  the  air  passages. 
Those  who  have  never  tried  it  may  not  realize  that  the  endoscopic  de- 
tection of  a  foreign  body  is,  even  when  presented,  not  always  easy  to 
the  inexperienced.  Prolonged  training  will  enable  the  experienced  endo- 
scopist instantly  to  recognize  any  departure  from  the  normal,  even  though 
the  exact  nature  of  the  condition  may  not  be  at  once  realized.  This 
is  a  valuable  time-saving  acquisition  to  be  striven  for.  It  must  be  re- 
m.embercd  that,  as  is  well  known  to  all  artists,  color  depends  largely 
on  the  intensity,  quality  and  direction  of  the  illumination.  Moreover,  it 
is  often  not  the  true  color  of  the  foreign  body  itself  that  presents,  but 
the  foreign  body  as  seen  through  a  filmy  coating  of  secretions  which  may 
be  tinted  with  pus,  blood  or  dissolved  material  from  the  foreign  body 
itself.  Therefore,  the  lube  must  be  advanced  slowly  and  carefully,  all 
secretions  being  sponged  away  ahead  of  the  tube-mouth  so  that  the  z^'all 
as  well  as  the  lumen  can  be  carefully  studied,  not  for  the  foreign  body 
alone,  but  for  evidences  of  traumatism  or  inflammatory  lesions  due  to 
its  presence.  As  stated  above,  the  color  of  a  foreign  body  as  seen  endo- 
scopically,  varies  with  the  degree  of  illumination.  As  a  rule,  however 
iron  and  steel  bodies  look  black  even  after  a  few  days'  sojourn,  no 
matter  how  highly  polished  they  may  have  been  when  they  entered. 
Xickel-plated  objects,  as  a  rule,  do  not  tarnish  so  readily.  Silver  ob- 
jects turn  black  very  quickly,  just  as  steel  and  iron  bodies  do.  Brass 
substances  corrode  quickly  and  soon  look  dark  brown  or  black.  The 
glint  even  of  nickel-plated  Ijodies  is  soon  dulled  by  secretions,  so  that 
taking  it  all  in  all,  the  endoscopist  will  usually  find  all  sorts  of  foreign 
bodies  to  be  grey,  or,  more  often,  almost  black  in  color,  with  the  excep- 
tion of  very  recently  aspirated  brass,  gold  and  bright  copper  substances, 
which  may  show  for  a  few  days  in  nearly  their  natural  colors.  As  a  rule, 
however,  the  bronchoscopist  who  is  looking  for  a  brightly  shining,  whit- 
ish glint  will  be  deceived  by  the  refraction  of  air  bubbles  and  the  spurs 
at  the  giving  off  of  the  different  branch  bronchi.  As  pointed  out  by 
Waggette  (Bib.  '>(u).  it  is  necessary  urgently  to  warn  the  beginner 
not  to  mistake  the  shar[),  white,  cartilaginous  division  between  two 
branches  for  a  foreign  body.  With  a  corroded  steel  or  iron  body,  show- 
ing black,  this  is  not  likely  t(j  occur;  but  if  the  operator  has  in  mind  the 
bright  silvery  whiteness  of  the  ordinary  ])in,  for  instance,  he  is  very  apt 
to  make  such  a  mistake  as  Mr.  Waggette  warns  against.  As  shown  by 
U.  i\.  Patterson  (Bib.  l.'Sll),  the  natural  color  of  a  foreign  body  mav  be 
such  as  to  render  its  contrast  with  the  surrounding  mucosa  so  slight 
as  to  make  j)rom])t  recognition  difficult.  This  is  an  important  point  to 
keep  in  mind. 


252  FOREIGN  BODIES  IN  LARYNX  AND  TRACHEA. 

Bronchoscopic  finding  of  a  foreign  body  in  the  traeheo-bronchial 
tree.  Finding  a  large  foreign  body  recently  aspirated  presents  no  espe- 
cial difficulties.  One  of  long  sojourn  may  be  hidden  by  secondary  pro- 
cesses ;  and  the  problem  then  presented  will  be  separately  considered. 
Small  foreign  bodies  are  in  some  cases  very  difficult  to  find.  Xot  be- 
cause of  any  difficulty  in  seeing  a  minute  object  when  such  objects  can 
be  brought  in  line  with  the  observer's  eye,  but  because  small  foreign 
bodies  may  be  located  "around  the  corner"  in  a  small  branch  bronchus, 
into  which  we  do  not  directly  look.  When  a  small  foreign  body,  such 
as  a  needle  or  a  pin,  has  penetrated  a  small  bronchus,  there  may  be  se- 
cretions emerging  from  the  little  bronchial  branch  that  will  betray  the 
presence  of  the  pin,  but  quite  as  often  there  is  nothing  in  the  way  of 
local  appearances  to  guide.  Under  such  circumstances,  the  methods  of 
localization  referred  to  in  a  previous  chapter  should  be  used  to  limit 
the  number  of  bronchi  to  be  searched  to  a  very  few.  In  the  absence 
of  such  means,  it  certainly  is  not  justifiable  to  search  every  bronchus  in 
the  entire  lobe,  and  still  less  is  it  justifiable  to  go  with  the  forceps  or 
probe  into  every  bronchus.  Having  narrowed  down  the  number  of  small 
bronchi  to  be  searched  to  a  few,  each  of  the  few  orifices  must  be  looked 
into  in  the  manner  shown  in  the  schema  Fig.  172.  The  bronchoscope, 
J;!,  is  introduced  as  far  as  possible  into  the  inferior  lobe  bronchus  and  the 
endoscopist  sees  ahead  the  orifices  of  two  or  more  branches,  (D.)  none 
of  which,  however,  shows  any  evidence  of  invasion  of  the  pin,  which  is 
below  the  level  of  the  \isual  axis,  and  is  hidden  by  the  intervening  tissue, 
C.  When  we  have  reason  to  suspect  such  a  condition  of  afi'airs  from 
the  radiographic  localization,  either  by  the  radiograph  with  film  overlay, 
or  by  radiograph  with  the  bronchoscope  in  position,  the 
tissue.  C,  must  be  pushed  backward  out  of  the  way  by  the  lip  of  the 
bronchoscope.  In  doing  this,  it  is  necessary  to  raise  the  head  of  the 
patient  and  in  certain  instances  it  will  be  necessary  to  raise  the  head 
and  shoulders,  the  head  being  flexed  forward  on  the  thorax.  In  this 
position,  the  bronchoscope,  as  shown  at  ^I.  will  afl:'ord  a  view  of  the 
point  of  the  pin  (E.).  The  large  amount  of  resiliency  of  the  bronchial 
tissues  permits  of  such  manipulation  without  injury,  provided  the  manip- 
ulations are  gentle.  It  is  very  easy  to  rupture  a  bronchus  by  pushing 
the  tube  with  too  much  pressure  into  a  bronchus  not  sufficientlv  large 
to  admit  the  tube.  Blind  probing  for  exploration  of  bronchi  suspected 
to  contain  the  intruder  is  dangerous  unless  done  with  extreme  caution. 
If  any  orifice  seems  at  all  suspicious  the  conical-ended  bronchoscope 
(Fig.  IS)  may  be  used,  or  a  closed,  plain,  straight  forceps  (Fig.  28) 
may  be  introduced  carefully  as  a  probe.  If  the  intruder  is  felt  the  for- 
ceps jaws  may  be  expanded  and  the  foreign  body  seized,  but  great  care 


FOREIGN  HODIKS  I.N    I.ARVNX  AND  TRACHEA. 


253 


must  be  used.  Under  no  circumstances  should  strong  traction  be  made. 
In  minute  bronchi  a  foreign  body  is  rarely  firmly  fixed  because  its 
distal  part  is  necessarily  small  or  it  could  not  have  entered.  If  a  spur 
between  two  bronchial  openings  is  grasped,  slight  traction  will  give  an 
elastic  sensation  that  can  readily  be  recognized  as  quite  different  from 
the  yielding  of  a  foreign  body  that  is  free  to  move.  Of  course,  a  pin 
whose  point  is  upward,  as  practically  all  are,  may  stick  into  the  bron- 
chial wall,  preventing  withdrawal.  This  would  give  the  same  sensation 
of  elasticity,  which  is  due  to  the  elastic  mobility  of  the  lung.     This  blind 


!  Hf:!'--; 


Fig.  i~2.  Schema  illustrating  the  author's  method  of  bringing  into  view  a 
pin  (A)  located  "around  tlic  corner,"  and  hidden  by  the  tissue  (C)  from  the  ob- 
server, who,  in  looking  through  the  bronchoscope,  B,  sees  only  empty  orifices  (D). 
Ry  raising  the  patient's  head  very  high,  the  lip,  L,  of  the  bronchoscope  displaces 
the  tissue,  C,  permitting  the  ob.server  to  see  the  point  of  the  pin  as  at  E.  The 
schema  was  drawn  by  the  author  after  thus  finding  a  pin  in  a  small  dorsal  branch 
of  the  inferior  lobe  bronchus.  He  has  used  the  principle  many  times  since  in 
branches  diverging  at  various  angles  and  twice  in  the  upper-lobe  bronchus. 


groping  is  dangerous.  Particular  care  must  be  used  not  to  mistake 
the  grating  sensation  of  the  probing  force])s  sliding  over  the  inner  wall 
of  the  bronchoscope  for  the  contact  of  a  foreign  body.  Under  no  cir- 
cumstances is  it  justifiable  to  use  toothed  forceps  for  probing. 

When  a  pin  is  located  so  as  to  have  its  long  axis  corresponding  to 
tlie  long  axis  of  the  bronchoscope,  the  point  of  the  pin  presenting  toward 
the  o])erator.  the  i)in  may  be  difficult  to  see.  though  as  a  rule  there  is 
movement  enough  to  the  whole  tree  to  throw  the  pin  at  various  angles 
so  that  it  is  only  for  a  moment  that  the  pin's  axis  exactly  coincides  with 
llie   visual   axis.     I'sually  als".  the  color  of  the  pin  is  black   from  cor- 


254  rOREIGX  BODIES  IX  LARYNX  AND  TRACHEA. 

rosion.  A  very  recently  aspirated  bright  ])in  may.  however,  be  mistaken 
for  a  string  of  mucus  or  a  division  spur.  Aluch  more  often,  however, 
the  reverse  mistake  is  made  ;  the  white  line  of  a  spur,  or  a  thread  of 
mucus  is  thought  to  be  the  foreign  body,  until  the  eye  has  become  edu- 
cated to  these  illusions. 

It  is  a  mistake  to  be  constantly  withdrawing  and  inserting  the  bron- 
choscope. The  author  in  208  cases  of  foreign  body  in  the  bronchus  did 
not  remove  the  bronchoscope  in  a  single  instance  until  entirely  through 
with  the  bronchoscopy.  This  is  not  mentioned  boastfullv  but  to  correct 
the  prevalent  misunderstanding  of  the  subject.  The  author  cannot 
bring  to  mind  any  reason  why.  starting  with  a  properly  selected  tube, 
the  bronchoscope  should  be  removed.  It  is  a  time-wasting  procedure 
even  if  it  does  take  but  a  few  moments.  If  there  should  be  any  trouble 
with  the  light,  the  light  carrier  can  be  withdrawn ;  but  this  should  not 
be  necessary  more  often  than  once  in  thirty  or  forty  cases ;  and  not 
oftener  than  once  an  hour  in  any  case.  Properly  illuminated,  the  life 
of  a  lamp  is  about  40  hours.  The  sponging  away  of  secretions  from 
the  field  keeps  the  lamp  clean  at  the  same  time,  as  previously  explained. 

Negative  endoscopic  findings  in  foreign  body  cases.  Many  cases 
come  to  the  endoscopist  erroneously  believing  that  a  foreign  body  has 
lodged  in  their  anatomy.  These  cases  may  or  may  not  need  endoscopic 
search  as  herein  elsewhere  indicated ;  but  if  searched  it  should  be  thor- 
oughly done.  There  is  another  class  of  negative  cases,  in  which  the 
foreign  body  has  probably  been  present  at  some  time  or  other.  These 
recjuire  very  careful  work.  In  the  trachea  and  bronchi,  evidence,  in  the 
form  of  local  reaction,  justifies  the  most  careful  and  persistent  search, 
because  the  chances  are  all  in  favor  of  the  foreign  body  still  being  pres- 
ent, possibly  hidden  in  swollen  mucosa  or  in  a  closed-off  bronchus,  either 
of  the  same  side  or  even  on  the  other  side.  In  other  words,  traumatism 
or  reaction  found  in  a  bronchus  indicates  that  the  foreign  body  is  pres- 
ent, but  it  does  not  necessarily  localize  it  to  the  side  on  which  the 
traumatism  is  seen,  because  of  the  well  known  tendency  of  foreign  bodies 
that  are  free  to  knock  in  the  air  passages  to  be  aspirated  into  the  op- 
posite side.  In  all  cases  of  doubt  as  to  the  localization  of  the  foreign 
body  we  must  do  a  bronchoscopy  as  well  as  an  esophogoscopy,  doing 
first  the  one  indicated  by  the  preponderance  of  evidence.  Furthermore, 
in  any  case  where  all  the  data  point  almost  conclusively  to  the  foreign 
body  being  in  the  esopliagus  or  in  the  air  passages,  as  the  case  may  be, 
and  failing  to  find  it  in  the  search  of  the  one,  we  must  then  search  the 
other  before  giving  a  positive  opinion  that  a  foreign  body  is  not  present, 
because  none  of  our  diagnostic  means  are  absolutely  reliable  negatively. 
In   the   esophagus   both   pyriform   sinuses   and    the    sub-cricopharyngeal 


FOREIGN    BODIES    I.N    LAKVNX    AND  TRACHEA.  255 

space  must  be  searched  with  a  large  tube  or  speculum.  The  possibility 
of  sharp-pointed  bodies  having  wandered  out  through  the  esophageal 
wall  must  be  borne  in  mind.  Such  bodies  usually  are  metallic  and  hence 
radiograph ically  discoverable;  but  occasionally  a  rib  bone  of  a  fish  w-ill 
thus  wander  and  will  not  show.  The  author  had  one  such  case,  also  a 
case  of  a  toothbrush  bristle.  In  none  of  these  was  an  esophagoscopy 
done.  Mr.  E.  D.  Davis  reports  the  case  of  a  boy  with  a  pin  that  could 
not  be  found  esophagoscopically,  but  which  seemed,  radiographically. 
to  be  in  the  retropharyngeal  space.  In  conclusion  we  may  say  that  no 
case  can  be  considered  to  have  been  endoscopically  explored  unless  the 
trachea,  right  and  left,  main,  inferior  and  upper  bronchi  and  the  middle 
lobe  bronchus  (present  on  the  right  side  only)  shall  have  been  examined, 
to  the  greatest  depth  reachable.  Nor  are  wc  ready  to  give  a  negative 
o[)iiiion  then.  The  hypopharynx  and  esopliagus  must  be  explored  from 
the  arytenoids  to  the  stomach.  This,  however,  must  not  be  misconstrued 
into  achising  that  thorough  exploration  must  be  completed  at  one  seance. 

Inasnuich  as  we  know  that  certain  foreign  bodies,  such  as  small  pins, 
may  be  present  in  the  bronchi,  as  shown  by  the  radiograph,  and  yet  not 
be  discoverable  by  bronchoscopy,  how  shall  we  be  certain,  in  case  of 
a  foreign  body  not  opaque  to  the  ray,  that  it  is  not  present  on  the  strength 
of  not  being  able  to  find  it  bronchosco])ically.  If  the  foreign  body  is  of 
such  small  size  that  it  can  enter  a  small  lir(jnchus  far  out  at  the  peri- 
j)hery.  it  is  impossible  to  be  certain.  If,  on  the  other  hand,  the  history 
mentions  a  nonfriable  foreign  body  of  such  size  that  it  cannot  enter  a 
bronchus  too  small  for  a  bronchoscope  to  follow  it.  we  ma\'  be  certain, 
after  a  careful  search,  that  it  is  not  jjresent  if  not  found.  If  the  body  is 
liable  to  be  comminuted  by  maceration  this  does  not  hold  absolutely 
true.  ( )ne  other  point  which  will  aid  sometimes  in  deciding  the  question 
is  that  we  may  be  able  to  state  from  the  apix-arances  of  reaction  around  a 
small  bronchus,  that  it  probably  contains  a  foreign  body.  This  is  only 
available,  however,  when  there  has  been  no  previous  bronchoscopy  which 
could  have  caused  irritation  by  probing  that  bronchus,  and  of  course  the 
error  must  be  avoided  of  mistaking  traumatism  of  a  foreign  body  which 
had  been  coughed  up  for  the  traumatism  of  the  reaction  of  a  foreign  body 
which  is  still  present. 

Oral  or  tracheotomic  bronchoscopy.  Which/*  Unfortunately  the 
statement  has  crept  into  the  literature  that  in  infants  or  small  children 
it  is  |)reUTabk'  to  do  a  tracheolomic  bronchoscopy.  In  the  opinion  of 
the  author  this  is  due  to  twcj  tilings:  1.  The  ignoring  of  the  precautions 
mentioned  under  subglottic  edema.    2.  The  fact  that  when  this  statement 

•Abstracted  from  the  author's  Rapport  at  the  International  Medical  Congress, 
London,  1913. 


256  FOREIGN  BODIES  IN  LARVNX  AND  TRACHEA. 

was  originally  made,  illumination  was  not  in  the  relatively  perfect  condi- 
tion that  is  seen  on  the  instruments  of  to-day.  In  making  this  state- 
ment, the  author  hopes  he  will  not  be  misunderstood  as  referring  to  any 
difference  between  distal  and  proximal  illumination.  He  means  simply 
that  the  light  on  all  forms  of  instruments  to-day  is  far  superior  to  what 
it  was  in  the  early  days.  At  that  time  it  made  a  great  difference  whether 
the  tube  was  a  long  or  a  short  one.  To-da\ ,  it  is  questionable  whether 
anyone  can  tell  by  looking  through  the  lumen  whether  the  tube  is  30 
cm.  or  50  cm.  The  author  has  often  tested  this  and  found  the  ob- 
server unable  to  tell  with  a  pair  of  concealed  tubes  which  was  the  longer 
and  which  was  the  shorter,  even  though  one  was  an  80  cm.  gastroscope. 
Therefore,  a  short  tube  has  no  advantage  so  far  as  illumination  is  con- 
cerned. In  regard  to  the  manipulation  of  forceps,  etc.,  an  additional 
length  of  10  to  11  cm.  is  of  no  advantage  whatever.  It  is  true  that  a 
somewhat  larger  tube  can  be  used  through  a  tracheotomic  wound  than 
through  the  glottis  with  safety  to  the  subglottic  structure,  but  Dr.  Ellen 
J.  Patterson  and  the  author  have  found  that  a  tube  of  4  mm.  internal 
diameter  is  amply  large  for  delicate  manipulations  under  the  guidance 
of  the  eye,  such  as  the  placing  of  a  hook  through  the  eye  of  a  shoe-but- 
ton in  the  bronchus  of  a  child  six  months  of  age.  If  one  is  not  accus- 
tomed to  work  through  small  tubes,  doubtless  it  is  better  to  do  a 
tracheotomic  bronchoscopy  than  to  force  a  large  tube  through  the  larynx. 
In  upper  lobe  bronchoscopy,  almost  as  favorable  an  angle  can  be  ob- 
tained by  shifting  the  tube  to  the  opposite  corner  of  the  mouth,  as 
could  be  obtained  by  a  tracheotomic  bronchoscopy,  provided  the  assist- 
ant holding  the  head,  and  the  operator  have  worked  years  together  so 
that  they  co-operate  and  the  head  of  the  patient  is  carried  along  with 
the  tube  to  the  extreme  opposite  position  from  the  lobe  to  be  explored. 
All  of  these  things  are  readily  demonstrated  on  the  patient,  but  unfor- 
tunately the  statements  in  the  early  literature  have  led  men  into  hasty 
tracheotomy  rather  than  to  develop  the  necessary  technic  to  work  with 
exceedingly  small  tubes  and  to  axoid  damage  to  the  subglottic  area 
Out  of  71  Hi  bronchoscopies  for  all  purposes,  no  one  in  the  author's  clinic 
has  ever  done  a  tracheotomy  for  the  purpose  of  bronchoscopy.  One 
tracheotomic  bronchoscopy  done  by  the  author  for  a  foreign  body  was 
in  a  case  where  the  general  surgeon  had  already  done  a  tracheotomy  for 
the  compressive  stenosis  due  to  a  goitre.  In  that  case  the  author  failed 
to  find  the  foreign  body,  a  small  jiin.  In  one  other  case,  also  in  his 
early  work,  he  did  a  treacheotoniic  bronchoscopy  in  a  foreign  body 
case  tracheotomized  for  dyspnea.  Both  cases  failed  to  convince  the 
author  that  there  is  any  advantage  in  the  tracheotomic  route.  With 
these  two  exceptions,  it  has  always  been  our  custom  to  insert  the  bron- 


FOREIGN  P.ODIF.S  IX  LARVXX  AXD  TRACHEA.  257 

choscope  through  the  inouth.  even  in  the  cases  already  tracheotomized 
for  dyspnea.  \'ery  often  i)atients  come  in  with  such  severe  dyspnea 
that  it  is  unwise  to  leave  them  over  night  without  a  tracheotomy.  In 
such  cases,  the  absolute  rule  in  tracheal  surgery  to  do  a  tracheotomy 
always  early,  never  late,  is  followed ;  but  in  the  first  management  of 
the  case  we  have  always  found  that  a  bronchoscope  introduced  through 
the  mouth  is  much  better  for  the  temporary  relief  of  dyspnea,  insuffla- 
tion of  oxygen,  etc.  In  foreign  body  cases  previously  tracheotomized 
the  bronchoscope  introduced  through  the  mouth  we  have  found  much 
more  freely  manipulated  and  much  more  satisfactory  to  work  with  be- 
cause the  patient's  head  is  very  much  less  in  the  way,  and  all  of  the 
movements  and  manipulations  are  the  usual  ones  in  peroral  endoscopy. 
The  author  hopes  the  foregoing  will  not  be  regarded  as  boasting. 
He  feels  sure  that  other  endoscopists  just  simply  have  not  tried  oral 
bronchoscopy  in  infants,  but  have  been  misled  by  early  statements  based 
upon  different  conditions,  and  especially  different  instruments.  The 
production  of  subglottic  edema  by  oral  bronchoscopy  in  children  was 
due  to  faulty  position,  too  large  tubes  and  other  preventable  factors 
that  will  be  considered  in  a  later  section.  The  preference  of  some  op- 
erators for  tracheotomic  bronchoscopy  has  been  due  to  the  erroneous 
position  of  the  head  used  in  oral  lironchoscopy.  As  elsewhere  mentioned, 
the  direction  of  the  trachea  is  backward  as  well  as  downward.  It  fol- 
lows that  a  tube  introduced  through  the  anterior  part  of  the  neck  will 
necessarily  be  of  a  great  advantage  compared  tc  a  tube  which  is  intro- 
duced through  the  mcjuth  if  the  head  of  the  patient  is  very  low.  If,  on 
the  other  hand,  the  head  (  recumbent  1  is  very  high,  there  is  absolutely 
no  advantage  in  direction  in  the  tracheotomic  route.  The  head  has 
usually  been  held  too  low  in  oral  bronchoscopy.  Figure  1G3  illustrates 
the  needlessness  of  tracheotomy  so  far  as  reaching  a  foreign  body  is 
concerned  (it  was  necessary  in  this  case  for  other  reasons).  The 
bronchoscope  shown  in  the  radiograph  is  passed  through  the  mouth 
and  shows  the  bronchoscope  at  a  farther  angle  toward  the  periphery 
than  was  necessary  to  reach  the  pin.  .A  tracheotomy  had  been  done  by 
ihe  previous  operator  in  the  hope  that  a  tracheotomic  bronchoscopy  might 
succeed  when  he  failed  at  an  oral  bronchoscopy.  The  author  worked 
through  the  mouth  only,  and  while  he  was  equallv  unsuccessful  in 
finding  the  pin,  the  point  here  made  is  that  so  far  as  reaching  a  foreign 
body  is  concerned  there  is  absolutely  no  advantage  in  angle  by  the 
tracheotomic  route.  The  radiograpli  was  not  made  for  the  purpose 
I  if  denionstraliiin  but  as  an  aid  to  the  working  out  of  the  problems  in 
that  [)articular  case,  llad  demonstration  been  the  object,  the  distal  end 
of  the  bronchoscope  coukl  easily  have  been  mo\ed  out  to  the  patient's 


258  FORKIGN   BODIES  IN   LARYNX   AND  TRACHEA. 

left  beyond  the  heart  shadow,  there  being  absolutely  nothing  in  the 
oral  route  to  prevent  such  an  angle.  So  far  as  any  advantage  in  lateral 
movement  is  concerned,  the  error  has  been  made  of  not  realizing  the 
wide  range  rendered  available  by  the  Boyce  position.  The  range  is 
shown  schematically  in  Fig.  lo.")  and  actually  in  the  living  patient  in 
Figures  l;Jii  and  1115.  Sharp  foreign  bodies,  especially  those  with  hooked 
extremities,  or  such  as  may  retjuire  a  complicated  procedure  for  re- 
moval, do  not  demand  a  traclieotomy,  but  simply  more  careful  work. 
In  the  hands,  however,  of  the  endoscopically  inexperienced,  it  is  per- 
fectly justifiable  in  such  cases  to  do  a  tracheotomy;  and  it  should  by 
all  means  be  done  in  preference  to  rough  and  violent  removal  after  an 
indiscriminate  forceps  seizure  of  the  foreign  body  at  any  point  that 
may  present.  Extremely  large  foreign  bodies  do  not  necessarily  demand 
tracheotomic  bronchoscopy.  .Any  intruder  that  has  gone  down  through 
the  glottis  can  be  brought  up  the  same  way,  if  turned  to  the  position 
of  least  resistance.  Thymic  tracheostenosis,  thyroid  anomaly,  acute  or 
chronic  laryngeal  stenosis  and  many  other  conditions  may  demand 
tracheotomy  and  the  author  would  be  the  last  one  in  the  world  to  argue 
against  its  prompt  and  early  performance.  But  in  this  chapter  are  pre- 
sented reasons  wh)-  it  is  needless  for  the  passage  of  a  bronchoscope.  I  ^ 
conclusion  the  author  would  strongly  urge  the  bronchoscopist  not  to 
resort  to  tracheotomic  bronchoscopy  at  the  second  trial.  If  the  first  bron- 
choscopy is  not  successful  after  fifteen  or  twenty  minutes  in  a  child  it  is 
better  to  desist,  wait  a  few  days  and  repeat  the  oral  bronchoscojjy  at 
least  twice  before  resorting  to  the  tracheotomic  route.  The  author  feels 
sure  that  a  large  number  of  the  reported  cases  where  the  first  bron- 
choscop)-  was  oral  and  the  second,  tracheotomic,  the  second  broncho- 
scopy would  have  been  just  as  successful  if  it  also  had  been  oral.  On 
the  other  hand,  the  author  regards  tracheotomy  as  perfectly  justifiable 
in  any  case  in  which  the  surgeon  in  charge  deems  tracheotomy  for  any 
reason  whatsoever  indicated  for  the  best  interests  of  the  patient.  In 
stating  his  personal  views  he  recognizes  the  advisability  of  everyone  de- 
ciding such  ([uestions  for  himself,  apropos  of  the  particular  case. 

COMPLICATIONS  AND  AFTF.R-F.FFlXTS  OF   BRONCHOSCOPY. 

After-care  in  endoscopic  foreign-body  cases.  All  foreign-body  cases 
should  have  a  special  nurse  night  and  day  so  that  a  careful  watch  may 
he  maintained  at  all  times.  The  possibility  of  the  patient  drowning  in 
his  own  secretions,  or  of  respiratory  arrest,  should  be  borne  in  mind  and 
under  no  circumstances  whatever  should  the  ]iatient  be  permitted  to 
leave  the  hospital  before  all  danger  of  complications  is  over.  In  the 
majority  of  cases  the  patient  could  go  home  the  same  evening  without 


KORKir.N    liOniES  IX   LAKVNX    AND   TRACHKA. 


259 


injiirx'  Init  occasidiially  ci implications  may  occur  and   it   is  better  to  he 
on  the  safe  side. 

General  reaction.  There  is  in  the  majority  of  instances  no  gen- 
eral reaction  followine;  a  hronchoscopy  in  a  patient  whose  temperature, 
pulse  and  respiration  are  normal  at  the  beginning.  Occasionally  there  is 
a  reaction  to  100'  F.  The  chart  in  such  a  case  is  reproduced  in 
Fig.  17o.      If,  however,  bronchopneumonia,  septic  pneumonia  and  other 


Fig.  17.^.  Chart  of  a  niaxinmtii  reaction  seen  after  bronchuscopic  foreign  body 
removal.  Patient  ncirnial  as  to  temperature,  jjiilse  and  respiration  1)efore  oper- 
ation. 


acute  conditions  are  present,  we  may  have  a  severe  reaction,  though 
it  is  very  rarely  fatal.  Lesser  degrees  of  virulence  of  infective  in- 
flammation  present  prior  to  bronchoscopy  may  produce  only  moderate 
reaction  as  shown  in  Fig.  ITl,  whicli  is  quite  typical.  Out  of  'M  cases 
of  children  in  which  the  larvnx  and  trachea  seemed  to  be  jierfectly  nor- 
mal, bin  in  which  a  loreign  bodv  was  found  in  the  l)r()ncbi,  there 
was  no  reaction  in  any   instance.     Thi'  leni])erature  did  not   rise  to    lOO 


260 


FOREIGN  BODIES  IN  LARYNX  AND  TRACHEA. 


in  any  but  one  case  and  the  children  seemed  normal  in  every  way  as 
to   breathing,   appetite,   and    general   condition.      In   one    instance   there 


w  U  W  U)  o  *  ^  *.o 

Fig.  174.     Chart  after  lironchoscopic  foreign  body  removal  in  a  case  in  which 
there  existed  previously  a  moderately  virulent  infective  tracheobronchitis. 

was  a  rise  in  temperature  to  10;!.  .\s  there  was  in  this  instance  no 
cough,  no  hoarsenes,  marked  respiratory  rise  nor  other  sign  pointing  to 
the  air  passages,  but   on   the  other  hand  gastro-intestinal   disturbances, 


FOREICX  BODIES  IN  LAKVNX  AND  TRACIIUA.  2(51 

which  were  promptly  relieved,  followed  by  [irompt  subsidence  of  the  tem- 
perature elevation,  Ur.  I'rice  concluded  that  the  condition  was  one  of  gas- 
tro-enteric  trouble  and  not  a  reaction  from  bronchoscopy.  On  the  other 
hand,  in  another  group  of  2()  cases,  which,  on  first  examination,  were 
seen  to  have  an  intense  laryngitis  or  tracheo-bronchitis,  either  from 
previous  attempts  at  removal  or  from  the  foreign  body  being  thrown 
about  the  interior  of  the  air  passages,  there  was  a  prompt  reaction  fol- 
lowing the  bronchoscopy  with  a  rise  of  from  one  to  two  degrees  in  the 
already  elevated  temperature.  This  rise  and  the  reaction  was  most  se- 
vere in  the  cases  associated  with  copious  pus  formation.  In  three  of 
these  cases  a  peanut  kernel  was  the  offending  substance,  and  this  par- 
ticular foreign  body  seems  to  have  a  peculiarly  irritating  effect  upon  the 
mucosa  of  the  lower  air  passages.  From  the  foregoing  statistics,  as  well 
as  from  the  general  recollections  of  clinical  observations,  the  author 
feels  justified  in  the  following  conclusions: 

1.  Bronchoscopy  carefully  done  in  children,  without  an  anesthetic, 
general  or  local,  is  unassociated  with  any  reaction  worthy  of  consid- 
eration, provided  the  child  beforehand  is  normal  as  to  temperature,  pulse, 
respiration  and  nearly  so  as  to  the  local  conditions  in  the  laryn.x.  trachea 
and  bronchi,  and  provided  the  technic  is  strictly  aseptic. 

2.  General  systemic  reaction  including  temperature  elevation,  ad- 
vance in  pulse  rate  and  respiratory  frequency  may  be  anticiijatcd  in  any 
case  where  the  temperature  is  already  above  100,  and  especially  in  such 
cases  as  have  a  severe  local  inflammatory  condition  in  the  larynx,  trachea 
or  bronchi. 

3.  The  most  severe  reactions  are  due  to  absorption  through  abra- 
sions of  the  epithelium.  These  abrasions,  when  occurring  from  the  for- 
eign body,  cannot,  of  course,  be  avoided,  but  abrasions  in  bronchoscopy, 
except  in  exceedingly  complicated  removals,  need  not  occur  if  great 
care  be  taken,  not  only  in  the  performance  of  bronchoscopy,  but  also 
beforehand,  to  see  that  all  of  the  instruments  are  free  from  roughness 
and  sharp  corners  or  angles.  \'on  Schrotter  (Bib.  50.5)  reports  a  rise 
of  pulse  to  HO  with  rapid,  irregular  heart  action  but  without  dyspnea, 
due  to  the  patient  having  swallowed  a  considerable  amount  of  air  during 
bronchoscopy,  causing  a  dilatation  of  the  stomach.  The  symptoms  all 
subsided  after  a  rest  in  bed. 

Shock.  To  the  writer's  knowledge  no  accurate  experimental  work 
has  been  done  in  regard  to  the  degree  of  shock,  if  any,  in  bronchoscopy 
and  esophagoscopy.  Taking  Crile's  definition  of  surgical  shock  as  a 
"low  blood  pressure."  the  author  has  never  seen  a  single  instance  in  any 
way  approaching  surgical  shock,  in  a  case  where  tliere  had  been  no 
operati\c  measures  other  lli;in  the  endoscopy.     .A  number  of  cases  have 


2f>2  FORF.rGN   BOniES   IN   LARYNX   AND   TRACHKA. 

had  severe  fatigue ;  especially  noted  in  children  after  a  prolonged  bron- 
choscop\'.  When  the  author  first  noted  the  interesting  observations  of 
Yandell  Henderson  on  the  acapneal  hypothesis  of  shock,  the  author  was 
surprised  that  nothing  of  the  kind  had  ever  been  noted  after  bronchoscopy 
without  anesthesia.  Careful  observation,  however,  revealed  the  fact  that 
respiration  far  from  being  excessive  is  so  much  interfered  with  by  spasm, 
cough,  and  holding  the  breath  that  it  seems  certain  that  there  is  a  hypop- 
nea  instead  of  a  hyperpnea.  This  observation  is  not  intended  as  applying 
in  one  way  or  the  other  to  the  theories  as  to  the  nature  of  surgical  shock. 
They  merely  go  to  show  that  unless  unduly  prolonged  there  is  nothing 
approaching  surgical  shock  from  a  carefully  done  bronchoscopy  or  esoph- 
agoscopy  when  no  traiuna  is  inflicted.  There  may  be,  and  doubtless  is 
in  many  cases,  a  drug  shock.  Sargnon  reports  a  case  where  a  tuber- 
culous pulmonary  hemorrhage  supervened  preventing  the  bronchoscopic 
extraction  of  a  pea,  the  patient  dying  twelve  hours  later.  Pulmonary 
tuberculosis  cannot  be  regarded  as  a  contraindication  to  the  removal  of 
a  foreign  body  and  it  w'as  perfectly  right  and  proper  in  this  case  to  make 
the  attempt.  Undoubtedly  the  hemorrhage  would  have  supervened  any- 
way in  a  very  short  time  so  that  such  a  case  can  hardly  be  regarded  as 
strictly  a  death  from  bronchoscopy.  Mosher  reports  central  hemiplegia 
during  bronchoscopy  imder  ether. 

Local  reaction.  Ordinarily  the  only  local  reaction  noted  is  a  slight 
laryngeal  congestion  producing  slight  hoarseness  which  disappears  in  a 
few  days.  If  dyspnea,  without  pneumonia,  supervene  it  is  usually  due 
to  one  of  three  things  : 

1.  Drowning  of  the  patient  in  his  own  secretions. 

2.  Laryngeal  edema. 
•5.     Subglottic  edema. 

Impending  drowning  of  the  patient  in  his  own  secretions  is  a  com- 
plication seen  by  the  author  in  a  number  of  cases.  The  subject  has  so 
many  imjjortant  bearings  that  it  is  separately  considered  under  "Diseases 
of  the  Trachea  and  Bronchi."'  Suffice  it  here  to  say  that  it  is  the  first 
thing  to  be  thought  of  in  dyspneic  cases  and  is  (|uicklv  relievable  by  the 
"sponge  ])uniping"  jjrocess.  In  a  number  of  instances,  the  child  has  be- 
come dyspneic  within  24  or  ;!(!  hours  after  the  bronchoscopy,  but  on 
passing  the  bronchoscope,  a  large  quantity  of  secretion  was  removed  with 
complete  re-establishment  of  quiet  respiration  and  the  disappearance  of 
the  dyspnea.  It  is  especially  to  be  anticipated  in  cases  of  peanut  kernels 
and  other  secretion-producing  foreign  bodies. 

Edema  of  the  supraglottic  larynx  sufficient  to  become  obstructive  is 
quite  rare.  The  only  case  of  the  kind  that  re(|uired  tracheotomy,  in  the 
author's  experience,  was  in  an  elderly  ]jatient  with  advanced  nephritis 


rORKIGX   BODIES  IN  LARYNX   AND  TRACHKA.  263 

Subglottic  edem-a.  The  causes  of  this  complication  in  the  author's 
opinion  are : 

1.  The  use  of  over-sized  tubes. 

2.  Undue  violence  in  insertion  of  the  bronchoscope. 

•■^.  Faulty  position  of  the  patient,  the  long  axis  of  the  trachea  not 
being  in  line  with  the  bronchoscope  as  the  latter  enters  the  trachea. 

4.  Faulty  position  of  the  patient  after  the  bronchoscope  is  intro- 
duced resulting  in  undue  pressure  by  making  the  larynx  the  fulcrum  of  the 
bronchoscopic  lever  instead  of  the  upper  thoracic  aperture. 

.J.  Trauma  by  extraction  of  the  foreign  body  wrongly  placed  with 
reference  to  the  long  diameter  of  the  glottis. 

Ci.  Trauma  in  the  application  of  local  anesthetics  through  the  glot- 
tis before  the  bronchoscope  is  introduced. 

7.  The  anatomic  ami  physiologic  nature  of  the  subglottic  tissue  is  a 
contributing  cause. 

8.  Infective  trauma  li\-  llie  foreign  l)ody  itself  prior  to  the  bron- 
choscopy is  uniloulitedly  a  coiUriluiting  factor. 

\'on  Eicken  has  re])orted  a  number  of  cases  in  which  a  subglottic 
edema  i)resent  before  bronchosco])y  increased  after  bronchoscopy  so  as 
to  require  tracheotomy.  Logan  Turm-r  has  scientifically  determined  that 
the  development  of  inflammatory  edema  of  the  larynx  is  dependent  upon 
three  factors.  1.  Tiie  intensity  of  the  inllammatory  process  producing 
it.  2.  The  site  of  the  infection.  .'!.  The  anatomic  arrangement  of  the 
loose  suljmucous  cellular  tissue  of  the  larynx.  The  bearings  of  these 
observations  upon  subglottic  edema  after  the  sojourn  of  a  foreign  body 
in  the  subglottic  region,  or  in  the  trachea  where  it  is  intermittently 
coughed  upward  toward  the  glottic  chink  and  aspirated  backward  again, 
is  self  evident,  but  it  is  hoped  that  still  further  study  by  this  eminent  au- 
thority will  llivdw  further  light  upon  the  occurrence  of  subglottic  edema 
without  general  laryngeal  edema,  after  bronchoscopy,  as  reported  by  a 
number  of  authors. 

The  author  may  be  biased  but  he  believes  that  the  ]M-oduction  of 
subglottic  edema  is  lessened  by  distal  illumination  by  permitting  the  use 
of  very  small  tubes  and  by  doing  away  with  the  heavy  handle,  thus  per- 
mitting of  the  utmost  delicacy,  and.  most  important,  the  thick  strong 
hcavv  laryngosco]iic  tube  is  not  introdnced  through  the  larynx.  The 
thinnest  lin'inings  bronchoscoi)e  at  the  laryngeal  part  of  the  tube  during 
bronchoscopy  is  ■;  mm.  and  this  Ilriinings  states  "Cannot  be  used  until 
the  child  is  from  I  to  ."i  nv  mills  old."  Conse(|uentlv  in  \ery  young  infants 
traciieotomy  has  to  be  resorted  to  because  as  llnniings  states:  "No  re- 
liance can  be  jiiaced  on  the  employment  of  tubes  narrower  than  7  milli- 
metres."    Tills  can  only  apply  to  proximally  lighted  tubes  which  re(|uire 


2(34  FOREIGN  BODIES  IN  LARYNX  AND  TRACHEA. 

not  only  a  relatively  large  lumen  for  illuminating  purposes  but  require  a 
relatively  thick  and  heavy  laryngoscopic  tube  outside  the  bronchoscopic 
tube,  because  by  this  system  the  laryngoscopic  tube  itself  is  pushed 
through  the  glottis.  By  the  author's  method  the  bronchoscopic  tube  is 
too  thin  and  light  to  be  used  to  produce  the  displacement  necessary  to 
expose  the  glottis,  and  with  distal  illumination,  a  -i  mm.  tube  is  quite 
practical  for  anyone  who  will  practice  with  it  a  while.  The  author  has 
done  a  number  of  peroral  bronchoscopies  for  diagnosis  in  suspected  thy- 
mic pressure  cases  in  new-born  infants  without  any  ill  effects  from  the 
use  of  the  4  mm.  distally  illuminated  tube.  In  the  author's  clinic,  both 
Dr.  Ellen  J.  Patterson  and  the  author  use  tubes  of  4  mm.  and  5  mm.  in- 
ternal diameter,  for  children  under  6  years  of  age,  the  4  mm.  tube  being 
for  infants  under  one  year.  Our  youngest  patient  from  whom  a  foreign 
body  was  removed  was  an  infant  of  2^/^  months.  This  was  a  common 
pin  removed  from  the  right  bronchus  with  a  tube  4  mm.  internal  diameter. 
Since  1911,  not  one  case  of  subglottic  edema  has  occurred  in  the  practice 
of  either  Dr.  Ellen  J.  Patterson  or  the  author  in  3(5  successful  removals 
of  foreign  bodies  in  the  trachea  and  bronchi  of  infants  under  one  year. 
Every  case  was  done  by  oral  bronchoscopy.  This  freedom  from  sub- 
glottic edema,  we  believe,  is  due  to  the  use  of  small  tubes,  close  atten- 
tion to  the  details  of  introduction  and  manipulation  herein  given ;  and, 
especially  to  the  aid  of  good  assistants — in  other  words  to  "'team  work." 
Stanton  A.  Friedberg  in  a  recent  case  reports  the  use  of  a  distally  illum- 
inated •")  mm.  tube  in  an  infant  of  3  months,  for  the  peroral  bronchoscopic 
removal  of  a  safety-pin  from  the  right  bronchus.  Considering  the  nature 
of  the  foreign  body  this  is  one  of  the  most  remarkable  cases  recorded, 
and  is  the  youngest  patient  from  whom  a  safety-pin  has  been  removed. 
Dr.  Friedberg  states,  "What  pleases  me  most  is  the  facility  with  which 
an  upper  bronchoscopy  was  performed  on  such  a  young  child."  Killian, 
himself,  recently  has  recognized  the  disadvantage  in  children  of  adding 
the  bulk  of  the  heavy  laryngoscopic  tube  to  the  bronchoscopic  tube  in  the 
larynx  and  has  devised  an  excellent  set  of  very  small  single  tubes  for 
children,  (Fig.  173),  to  obviate  the  bulk  of  the  double  tube.  These  tubes 
Killian  inserts  with  a  mandrin  and  illuminates  with  a  Kirstein  headlight; 
though  the  tubes  are  also  arranged  to  fit  the  Briinings  or  Kahler  hand- 
lamp.  Faulty  direction  of  the  tube  on  introducing  may  easily  cause 
trauma  by  gouging  into  the  subglottic  wall,  if  the  axis  of  the  broncho- 
scope and  that  of  the  trachea  do  not  coincide  at  the  moment  the  tube 
passes  the  glottis.  In  ten  different  publications  within  the  last  two  vears, 
the  operators  stated  they  placed  the  patient  in  the  Rose  position.  If  the 
patient  actually  was  in  the  Rose  position,  he  was  just  exactly  rightly 
placed  for  the  bronchoscope  to  gouge  into  the  subglottic  wall  and  to  risk 


FOREIGN  BODIES  IN  LARYNX  AND  TRACHEA. 


2G5 


a  production  of  subglottic  edema,  especially  if  the  head  of  the  patient  was 
a  little  more  to  one  side  than  the  other.  Mention  is  made  in  the  chai>- 
ter  on  introduction  of  the  bronchoscope,  of  the  necessity  for,  and  method 
of,  avoiding  the  use  of  the  larynx  as  a  fulcrum  and  the  bronchoscope  as  a 
lever,  because  not  only  is  the  bronchoscopic  freedom  of  movement  thus 
hampered  but  the  incidental  trauma  is  a  fruitful  source  of  subglottic 
edema.  The  operator,  who  expects  by  means  of  heavy  handles,  and  spe- 
cial leverage  to  get  along  with  an  illy  trained  assistant  by  dragging  his 
patient  around  with  his  instrument  until  he  can  find  the  lumen  he  seeks, 
will  have  fre(juent  subglottic  edemas  :  and  if  he  cannot  improve  the  tech- 
nic  he  had  better  do  a  tracheotomic  bronchoscopy  in  order  to  leave  the 
larynx  out  of  harm's  way.    P.ronchoscopy  should  be  a  gentle  art. 

Treatment.  When  subglottic  edema  is  present,  the  patient  should  be 
closely  watched  and  secretions  should  be  ])romi)tly  removed,  though  if  it 
is  certain  that  the  trouble  is  due  solelv  to  the  subglottic  swelling,  it  would 


Fii,.  175.  Killian's  new  tubes  for  children.  What  resemble.s  an  inner  tube  is 
really  a  mandrin  for  insertion,  to  obviate  the  use  of  the  bulky  double  tube.  They 
will  lit  the  Briinings  or  Kahlcr  handlani]) ;  Init  Killian  uses  the  Kirstcin  headlight. 
Six  sizes  are  required. 

4.5  mm.  lor  children  54  to  57  cm.  body  length. 

5.  mm.     "  "         ;8  to  64  cm.    "  " 
5.5  mm.     "           "          (15  to  70  cm,     " 

6.  mm.     "  "  71  to  85  cm.     " 

6.5  mm.     "  "         86  to  100  cm.     "  " 

7.  mm.     "  "        loi  to  120  cm.     "  " 

perhaps  be  better  not  to  pass  the  brcjnchoscope  for  the  removal  of  se- 
cretions, but  to  proceed  to  a  .tracheotomy.  Intubation  should  never  be 
used,  as  it  is  not  safe  in  these  cases  and  is  very  likely  to  lead  to  an  after 
stenosis.  The  same  ma\'  be  said  (jf  a  verv  high  tracheotomy  in  which  the 
reaction  around  the  cannula  may  result  in  a  stenosis  from  perichondritis 
or  cicatricial  contraction  which  will  re(|uire  a  long  period  of  treatment  for 
cure.  When  done  for  subglottic  edema,  the  tracheotomy  should  be  below 
the  second  ring  of  the  trachea. 

The  patient  should  be  decaniuilated  in  a  few  days.  Should  the  edema 
become  chronic  and  prevent  decannulation,  direct  galvano-cauterization  as 
elsewhere  herein  explained,  .should  be  done.  The  treatment  of  other 
complications  arc  within  the  province  of  the  internist  and  pediatrist. 


CHAPTER     XIV. 

Removal  of  Foreign  Bodies  from  the  Larynx. 

Syiii[<tonis  and  diagnosis.  The  older  laryngologic  works  contain 
lengthy  descriptions  of  signs  and  symptoms  by  which  the  presence  of  a 
foreign  body  in  the  larynx  was  to  be  differentiated  from  neoplasm  and 
other  diseases,  particularly  laryngitis,  diphtheria,  and  spasmodic  croup. 
This  was  necessar\  because  of  the  difficulties  attending  mirror  laryngo- 
scopy in  children.  To-day  the  promptness  and  certainty  of  diagnosis  by 
the  direct  method  of  examination  has  rendered  all  this  unnecessary.  In 
the  earlier  days  the  usefulness  was  limited  because  it  was  thought  that 
anesthesia  was  necessary ;  but  as  the  author  has  abundantly  proven,  no 
anesthetic,  general  or  local,  is  necessary  for  a  diagnostic  direct  laryngos- 
copy in  any  infant  or  older  child.  The  prompt,  safe  and  successful  re- 
moval of  foreign  bodies  from  the  larynx  is  one  of  the  greatest  achieve- 
ments of  direct  laryngoscopy.  Xot  only  is  it  exceedingly  difficult  to  see  the 
larynx  of  a  child,  but  even  if  seen,  removal  by  the  indirect  method  is  of 
such  extreme  difficulty  that  tracheotomy  has  usually  been  done  in  days 
jiast  in  preference  to  attempting  indirect  removal  without  general  anes- 
thesia, and  of  course  general  anesthesia  is  absolutely  contraindicated  be- 
cause of  the  laryngeal  obstruction.  (  )n  the  other  band  by  the  direct  method 
foreign  bodies  can  be  removed  from  the  larynx  of  children  without  any 
anesthetic,  general  or  local  and  without  tracheotomy,  .\nother  great  ad- 
vantage of  the  direct  method  is  that  in  case  of  impacted  foreign  bodies 
which  have  to  be  rotated  for  safe  remoxal.  the  rotation  is  easily  accom- 
plished by  means  of  the  straight  instruments.  This  was  impossible  with 
the  angular  instruments  rei|uired  by  the  indirect  method.  Such  a  case  is 
shown  schematically  in  Fig.  17(i.  which  illustrates  the  difticulties  presented 
by  the  firm  lodgement  of  a  safety-pin  in  the  edematous  larynx  of  an  in- 
fant of  8  months.  Notwithstanding  the  achievements  of  the  direct 
method  it  is  still  quite  common  to  have  children  with  foreign  bodies  in 
the  larynx  given  antitoxin  on  an  erroneous  diagnosis  of  laryngeal  diph- 


RKMOVAL  OF  FORKIGX  BOPIF.S  I'ROM  THE  LARYNX.  267 

theria.  Of  course,  if  for  any  reason  a  direct  laryngoscopy  is  not  to  be 
had  promjjtly  because  of  lack  of  instruments  or  of  familiarity  with  their 
use,  it  is  perfectly  right  to  give  antitoxin  rather  than  delay  21  hours  for 
a  diagnosis,  liul  when  the  da)-  shall  have  arrived  that  every  laryngolog- 
ist  and  every  pediatrist  will  be  able  to  examine  the  laryn.x  of  any  child 
without  any  anesthetic,  general  or  local,  the  necessity  for  "a  shot  in  the 
dark"  will  cease  to  exist.  Harmon  Smith  (Bib.  'i09 )  reports  a  very  in- 
teresting case  (if  a  closed  safety-pin.  The  patient  had  not  only  been 
gi\en  antitoxin  for  diphtheria,  but  had  been  intubated.  The  intubation 
tube  was  coughed  out,  leav'ing  the  pin  in  situ.  Harmon  Smith  discovered 
and  removed  the  pin  by  direct  laryngoscopy,  and  very  justly  urges  that, 
in  all  cases  in  wliich  cultures  are  negative  and  no  membrane  is  in  evi- 
dence, the  larynx  and  the  trachea  should  be  examined  bv  the  direct 
method  "if  for  mi  other  reason  than  to  exclude  the  presence  of  a  for- 
eign body."  .\lmost  every  endoscopist  has  had  a  similar  experience. 
When  we  add  to  such  occurrences  the  great  number  of  papillrjma  cases 
the  neglect  of  direct  laryngoscopy  begins  to  assume  the  aspect  of  serious 
lack  of  efficiency.  Jn  one  case  reported  repeated  operations  for  papil- 
loma had  been  pi-eviously  done,  the  fungations  having  been  mistaken  for 
neoplasms. 

Many  cases  of  foreign  body  in  the  larynx  are  immediately  fatal 
as  the  columns  of  the  newspapers  show.  Many  others  are  extremely 
dyspneic  when  they  come  to  the  laryngologist.  Xo  physician  or  sur- 
geon should  iiesitate  to  do  an  immediate  tracheotomy  in  such  cases.  In 
lesser  degrees  of  dyspnea  the  child  must  be  carefuU)-  watchetl  until  pre- 
parations for  direct  laryngoscopy-  can  be  made,  because  of  the  risk  of  a 
sudden  increase  of  dyspnea  from  a  shift  of  the  foreign  body,  drowning 
of  tlie  patient  in  his  own  secretions,  spasm,  edema,  etc.  1 'reparations 
for  a  tracheotomy  should  also  be  made,  not  that  the  direct  laryngoscopy, 
if  carefully  done,  would  ordinarily  provoke  stenosis,  but  the  foreign 
body  might  be  siiifled.  It  is  well  to  remember  that  these  cases  often 
come  in  exliausted  because  for  days  and  nights  they  have  been  too  busy 
fighting  for  air  to  either  eat  or  sleep.  It  re(|uires  but  little  to  cause  them 
to  give  up  the  fight  because  of  exhaustion.  For  this  reason  also  it  is 
never  wise  to  prolong  the  examination.  They  cannot  stand  for  long  the 
spasmodic  reflex  closure  of  the  glottis. 

Preliminary  c.vamiiiatian.  .As  previously  stated,  in  every  case  of 
foreign  body,  regardless  of  whether  it  is  expected  to  be  in  the  larynx, 
trachea,  bronchi  (jr  esophagus,  indirect  mirror  examinations  should  be 
made,  if  the  patient  be  old  enough.  The  patient  should  be  recumbent. 
In  a  number  of  cases  where  a  foreigi-i  1)0(1\-  was  susjiected  by  the  patient. 
a  local  lesion  has  been  found  ;   in   three  instances  tuberculosis  had  pro- 


268  REMOVAL  OF  FOREIGN  BODIES  FROM  THE  LARYNX. 

duced  no  symi)toms  until  the  patient  strangled  on  some  article  of  food 
which  was  thought  to  have  entered  the  larynx.  On  the  other  hand,  es- 
pecially if  granulations  are  present,  the  endoscopist  must  be  on  his  guard 
against  making  a  diagnosis  of  disease  from  the  appearances  of  inflam- 
matory changes  which  may  be  secondary  to  the  presence  of  a  foreign 
body.     Quite  a  number  of  such  cases  have  been  reported  and  the  author 


Fig.  1/6.  Schema  sliowing  lodgement  of  a  safety-pin  in  the  larynx  of  a  male 
infant  eight  months  of  age.  The  pin  was  pushed  downward,  rotated  and  re- 
moved with  its  greater  plane  sagittally.  Rotation  would  have  been  impossible  with 
the  angular  instruments  necessary  in  direct  methods. 

has  seen  two  cases  of  foreign  body  in  the  larynx  that  simulated  tuber- 
culous perichondritis.  If,  however,  a  foreign  body  is  discovered  by  the 
indirect  method,  the  removal  should  not  be  attempted  by  the  indirect 
method  unless  the  operator  be  one  of  those  experts  who  by  long  prac- 
tice with  indirect  operating  have  developed  an  unusual  degree  of  skill. 
If  an  indirect  attemi)t   is  made  the  patient   must  be  recumbent   in  the 


REMOVAL  OF  rORKIGN   UODIKS  FUnM   THE  LARYNX.  269 

author's  position.  (Fig.  73a).    Quite  a  large  proportion  of  foreign  bodies 
in  the  lower  air  passages  have  been  dislodged  and  lost  downward. 

Tecluiic  of  direct  luryngoscof'ic  removal  of  foreign  bodies.  Differ- 
ing from  foreign  bodies  elsewhere  the  first  step  is  not  to  study  out  the 
mechanical  ])roblem.  Because  of  the  risk  of  loss  downward,  it  is  best 
to  seize  the  foreign  body  as  soon  as  seen  and  to  proceed  to  study  how 
best  to  disim])act  the  intruder.  If  the  larynx  contain  suspicious  gran- 
ulation tissue  it  is  as  well  to  remove  it.  as  removal  will  cause  no  more 
bleeding  than  sponging,  and  in  the  event  of  no  foreign  body  being  found 
the  examination  of  the  tissue  may  contribute  to  the  diagnosis.  The  me- 
chanical problems  of  disimpaction  are  similar  to  those  in  the  trachea  and 
bronchi  and  need  not  be  extensively  considered  here.  Because  of  the 
chink-like  lumen  of  the  glottis  and  the  frequency  with  which  part  of  a 
foreign  body  gets  hooked  below  the  lateral  glottic  borders,  rotation  is 
more  frequently  required  for  disimpaction.  Rotation  will  also  be  re- 
quired for  foreign  bodies  engaged  in  one  ventricle  or  transfixed  with 
one  end  in  each  ventricle.  Rotation  is  best  accomplished  with  the  rotation 
forceps.  (Fig.  ilO).  The  problem  of  the  foreign  body  hooked  below  the 
glottis  is  well  illustrated  in  the  schema.  Fig.  176.  In  this  case  trauma 
would  have  resulted  from  its  being  brought  up  through  the  glottis,  so  it 
was  rotated  so  as  to  bring  its  greater  plane  sagitally,  permitting  easy  and 
harmless  withdrawal.  Not  infrequently  a  child  will  come  in  completely 
a])honic  from  a  foreign  body  wedged  in  the  subglottic  space  and  pro- 
jecting upward  between  the  cords  which,  in  consec|uence,  cannot  approx- 
imate. Usuall\-  such  a  position  of  the  foreign  body  results  from  cough- 
ing the  intruder  up  from  below.  Careful  work  with  the  alligator  forceps, 
the  ])atient  being  recumbent,  will  usually  succeed,  especially  if  no  anes- 
thesia is  used.  'J'he  application  of  a  local  anesthetic  may  mechanically 
dislodge  the  intruder,  and  the  relaxation  of  a  general  anesthetic  may  re- 
lease it.  In  some  cases  it  will  be  found  that  a  tracheally  lodged  foreign 
body  can  be  easily  seen  through  the  glottis  and  can  Ik-  removed  bv  in- 
serting the  alligator  forceps  during  inspiration.  This  should  only  be 
done,  however,  where  there  is  no  great  dys])nea.  and  where  the  foreign 
body  is  small  in  one  diameter  and  large  in  the  other,  allowing  plenty  of 
air  to  pass  on  each  side,  and  also  allowing  a  ready  grip  with  the  forceps 
inserted  so  that  the  jaws  will  open  at  right  angles  to  the  longest  pre- 
sented diameter.  The  intruder  must  be  turned  so  that  its  longest  diam- 
eter comes  sagitally  llirough  liie  glottis.  For  this,  Mosher's  forceps  are 
excellent. 


CHAPTER     XV. 

Mechanical  Problems  of  Bronchoscopic 
Foreign  Body  Extraction. 

The  greatest  triumph  of  bronchoscopy  over  thoracotomy  is  in  the 
low  mortaHty  of  bronchoscopy.  Esophagoscopy  presents  a  simihir  tri- 
umph. The  problem  is  not  simply  to  remove  the  foreign  body.  A  strong 
forceps  and  main  strength  would  do  that.  The  problem  is  the  removal 
without  endangering  the  patient's  life.  A  careful  study  of  the  mechanical 
problems  presented  will  always  discover  a  safe  method  of  removal.  In 
view  of  this,  the  temptation  to  remove  the  body  at  all  hazards  once  it  is 
grasped,  must  be  resisted.  The  endoscopic  extraction  of  a  foreign  body 
is  a  mechanical  problem  pure  and  simple.  A  bad  mechanic  will  either 
fail  to  remove  the  foreign  body  or  will  kill  the  patient  or,  alas,  will  do 
both,  as  has  already  happened  a  number  of  times,  to  the  undeserved 
discredit  of  bronchoscopy  and  esophagoscopy.  Being  a  mechanical  prob- 
lem it  can  be  best  illustrated  by  reference  to  every  day  experience  in  me- 
chanics. For  instance,  a  cap-screw  is  broken  ofif  flush  with  the  surface 
of  the  cylinder  of  an  automobile  engine.  The  repairman  who  is  not  a 
mechanic  will  ])ound  away  with  a  ]ninch  in  an  effort  to  turn  the  screw 
out.  He  breaks  the  entire  engine  casting  by  hasty,  ill-[)lanned  or  rather 
unplanned  efl^orts  at  removal.  The  good,  careful  mechanic  will  care- 
fully cut  a  slot  in  the  broken  screw.  This  slot  will  enable  him  to  use  a 
screw-driver,  by  means  of  which  he  will  remove  the  screw  without  dam- 
age to  the  engine,  in  less  time  than  it  took  the  unmechanical  repairman 
to  ruin  the  entire  engine.  L'nfortunately,  endoscojjic  work  has  been  done 
on  the  basis  that,  left  in  situ,  the  foreign  body  would  probably  be  fatal ; 
consequently,  any  violence  in  removal  was  justifiable.  The  basis  is  in- 
disputable, but  the  inference  is  erroneous.  In  the  solution  of  the  me- 
chanical problems  involved,  as  well  as  in  their  execution,  the  utmost  pa- 

*I-ecture  given  by  the  author  before  the  New  York  State  Medical  Societ.v,  Sec- 
tion on  Laryngology,  New  York  City,  April  30,  1914.    Revised  and  supplemented. 


MECUANirAI.  I'KllKI.I-.MSlll-   IMKiaCN  liODV  EXTRACTION.  371 

tience  is  necessary.  The  hasty,  brilliant  man  may  remove  the  foreifjn 
body,  but  the  removal  may  be  fatal  to  the  patient. 

As  Briinings  has  well  said,  '"The  description  of  operative  technic, 
which  affords  such  an  unlimited  scope  to  the  person  of  skill,  ingenuity 
and  talent  for  mechanical  adaptability,  encounters  quite  special  difficul- 
ties." 

Only  general  rules  can  be  laid  down  ;  and  the  author  wishes  par- 
ticularly to  warn  any  one  from  taking  any  of  the  following  suggestions  as 
absolute  for  application  to  a  case  which  may  present  itself.  Every  case 
must  be  dealt  with  upon  its  own  merits,  and  variations  from  any  rules 
will  naturally  suggest  themsehes  to  the  mechanically  inclined.  The  au- 
thor can  say  this,  however,  that  every  statement  made  herein  as  to  me- 
chanical problems,  unless  otherwise  stated,  is  a  note  made  at  the  time 
when  the  particular  plan  had  resulted  in  a  successful  issue.  Fast  e.x- 
perience  becomes  a  guide  for  future  jjrocedures,  but  it  is  a  guide  that 
must  not  be  followed  implicitly  without  reasoning  as  to  whether  or  not 
it  is  applicable  to  the  particular  case  in  question.  It  must  be  remem- 
bered, also,  that  there  is  more  than  one  way  of  doing  things  mechanical, 
though,  as  applied  to  foreign  body  extractions,  it  will  usually  be  found 
that  one  plan  is  better  than  another,  because  of  the  personal  equation  of 
the  operator.  For  instance,  nearly  every  endoscopist  has  his  own  i)in 
closer.  The  chapter  of  case  rejjorts  will  contain  notes  of  how  the  me- 
chanical problems  were  dealt  with. 

The  lip  of  the  bronchoscope  and  esophagoscope  is  one  of  the  most 
important  factors  in  the  solution  of  the  mechanical  problems  of  foreign 
body  extraction.  Under  the  manipulation  of  the  well-trained  left  hand, 
co-ordinating  with  the  forceps,  hook  or  snare  in  the  right  hand,  the  en- 
doscoi:ist  has  a  binimuial,  eye-guided  control  that  can  accomplish  what 
seems  wonders  to  an\()ne  whose  work  has  been  limited  to  square-ended 
tubes  and  unaided  right-handed  forceps  manipulations.  The  bimanual 
control  is  p()s--iblc  (inly  because  of  the  li|i  of  the  slanted  tube-mouth. 
This  lip  is  of  the  greatest  aid  in  making  a  space  at  the  side  of  a  foreign 
body  where  the  intruder  imjiinges  on  the  bronchial  wall,  for  the  inser- 
tion (if  the  furceps  jaw.  It  forms  a  shield  or  protectnr  that  can  lie 
slijiiied  under  the  point  ot  a  jiin  or  other  sharp  foreign  body  and  can 
make  counter-pressure  on  the  tissue  while  the  fcjrcejis  are  disembedding 
the  point  ot  the  foreign  bixh.  In  nian\  other  wavs  it  can  be  used  to  as- 
sist once  the  habit  of  working  with  a  knowledge  of  its  direction  in  rela- 
tion to  the  hanille  is  mastered  by  practice.  The  lip  cannot  be  seen  as 
such  in  looking  through  the  tube.  One  of  the  most  imjiortant  ]ioinls  in 
foreign  body  extraction  is  to  introduce  the  tube  until  the  distal  end  ar- 
rives at  the  [iroper  distance  above  the  foreign  body.     What  constitutes 


273  MECHANICAL   PROBLEMS  Or    FOREIGN  BODY  EXTRACTION. 

the  proper  distance  varies  in  the  different  cases.  So  far  as  merely  see- 
ing the  object  is  concerned,  the  tube  need,  ordinarily,  not  be  very  close 
to  the  foreign  body.  But  the  mechanical  problem  of  removal  is  closely 
concerned  with  the  distance  of  this  rigid  tube-mouth,  and  the  tube  must 
be  "anchored"  in  the  chosen  place  by  the  left  third  and  fourth  fingers 
hooked  over  the  upper  alveolus  (Fig.  137),  while  the  right  thumb  and 
first  two  fingers  make  lateral  pressure  to  swing  the  bronchoscope,  if  need- 
ed, to  displace  swollen  mucosa,  open  the  lip  of  a  bronchial  orifice  or  the 
like.  Never  go  into  any  foreign  body  case  hastily  or  unprepared  with  the 
idea  of  taking  a  preliminary  obser\ation.  Often  the  first  sight  of  a  for- 
eign body  is  the  best  you  will  ever  get.  If  not  immediately  removed  it 
may  become  more  difficult  later,  through  being  hidden  by  mucosal  swell- 
ing, dropping  into  a  smaller  bronchus,  passing  down  the  esophagus,  etc. 

The  use  of  iwoks  will  be  mentioned  in  connection  with  various  me- 
chanical problems.  The  Lister  hook  is  very  useful.  Small  probe  point- 
ed hooks  are  excellent  but  a  right  angle  is  sufficient  for  most  purposes. 
Hooks  with  a  curve  greater  than  a  right  angle  are  very  apt  to  become  en- 
gaged in  small  orifices  and  to  be  very  difficult  in  removal. 

The  use  of  forceps  in  endoscopic  foreign  body  extraction.  The  au- 
thor uses  two  different  strengths  of  forceps.  The  regular  forceps  is  so 
strong  and  firm  that  the  full  amount  of  strength  of  an  ordinary  man's 
fingers  can  be  applied  without  bending  or  breaking  the  forceps.  These 
are  necessary  in  foreign  bodies  which  present  a  hard,  smooth  conical 
end  towards  the  operator,  the  strength  of  instrument  being  necessary 
not  for  traction  but  to  pre\ent  the  forceps  slipping  oft"  such  bodies.  These 
force])s.  however,  are  not  so  well  suited  to  extremely  delicate  manipula- 
tions because  they  are  larger  in  size.  The  more  delicate  forceps  are  jusi 
one-half  the  dimensions  of  the  larger  ones  and  they  will  suffice  for  ordin- 
ar}'  extractions,  but  they  must  be  used  with  consideration  and  care,  or 
they  may  get  bent  or  broken.  Or,  indeed,  the  delicate  or  friable  foreign 
bodies  may  get  bent  or  broken.  As  in  all  other  mechanical  problems, 
and  practically  all  of  the  problems  in  foreign  body  extraction  are  me- 
chanical, the  operator  must  use  judgment  and  adjust  the  means  to  the 
end.  It  is  absolutely  essential,  for  accurate  work,  that  the  forceps  be 
seen  to  close  upon  the  foreign  body.  This  is  one  of  the  chief  reasons 
why  the  author  prefers  distal  illumination.  The  illumination  of  the  field 
is  just  as  good  after  the  forceps  are  introduced  as  it  was  before,  and  all 
the  operator  has  to  do  is  to  look  i)ast  the  near  part  of  the  forceps.  The 
practiced  eye  will,  in  every  case,  see  the  jaws  close  under  the  guidance 
of  the  eye.  even  in  the  4  mm.  tube,  of  whose  lumen  the  forceps  occupies 
nearly  one-half  of  the  entire  diameter.  The  crevice  remaining  is  suffi- 
cient because   the   illumination   is  uninterfered  with.     However   reliable 


MliCHAXICAL   I'KOBLHMS  OF  FOREIGN   BODY  EXTRACTION.  273 

the  sense  of  touch,  there  are  many  thhigs  in  foreign  body  extraction  in 
wliich  the  sense  of  touch  alone  will  not  be  a  sufficiently  accurate  guide 
to  safety  and  success.  .Most  iniiiortant  is  development  of  the  ability  to 
gauge  depth  with  one  e\e  alone.  Those  who  have  never  tried  it  think 
that  this  is  easy,  those  who  have  tried  it  only  once,  think  it  is  impos- 
sible. Those  who  h.nve  the  natural  aptitude  to  begin  with  and  who  de- 
vote a  sufficient  length  of  time  to  it,  can  develop  this  sense  to  an  extent 
that  seems  incredible.  When  one  sees  a  foreign  body  for  which  one  has 
been  searching  there  is  naturally  great  eagerness  to  seize  it  and  remove 
it.  'i'his  impulse  must  be  resisted  and  a  careful  study  of  the  size,  shape 
and  ]iosition  of  the  foreign  body  and  its  relation  to  surrouncUng  struc- 
tures must  be  clearly  determined  before  any  attempt  at  extraction  is 
made.  To  seize  it  and  tear  it  out  regardless  of  the  harm  that  may  he 
done  is  to  court  disaster,  for  however  successful  it  may  be  in  a  possibly 
considerable  number  of  cases,  the  endoscopist  is  bound  to  encounter 
other  cases  in  which  such  a  procedure  will  be  fatal,  and  needlessly  fatal. 
In  apiiroaching  a  foreign  body  with  the  forceps,  to  grasp  it,  careful 
watch  should  be  kept  by  the  eye  to  see  that  the  forceps  do  not  touch 
the  foreign  l)(idy  licfore  the  jaws  are  expanded,  as  this  may  have  the  ef- 
fect of  driving  the  foreign  body  more  deeply.  The  forceps  are  inserted 
through  the  bronchosco])e  closed  and  are  allowed  to  expand  when  they 
are  within  a  few  niillimelers  of  the  intruder.  In  using  forceps,  the  tube 
mouth  must  not  be  so  close  to  the  foreign  body  as  to  hinder  the  expan- 
sion of  the  forceps  jaws,  unless  the  intruder  be  small,  such  as  a  pin  or  a 
needle,  in  which  case  ample  ex|)ansion  can  be  h.-.d  within  tlie  tube.  This 
is  the  better  way  to  w^ork  in  case  of  pins  or  needles,  because  the  points 
can  be  inore  or  less  fixed  by  the  jiressure  of  the  tube  while  the  forceps 
are  being  placed.  The  first  trial  of  forceps  extraction  is  always  the  best 
ojiportunity  for  reinoval.  because  of  secretions,  possibly  blood  stained, 
set  free  as  soon  as  the  foreign  body  is  disturbed.  Therefore,  the  proper 
placing  of  the  forceiis  on  the  prii|K.-r  part  of  the  foreign  body  to  insure 
its  extraction,  should  be  plaimed  before  the  forceps  are  inserted.  As  ex- 
plained under  eso|)hagoscopy,  the  point  at  which  the  foreign  body  is  seen 
makes  a  great  difference  with  certain  foreign  bodies  which  should  be 
allowed  to  turn  in  order  to  present  their  least  diameter  to  the  cross  sec- 
tion of  the  bronchus ;  and  also,  in  certain  cases,  to  turn  where  a  point  or 
rough  place  on  the  foreign  body  will  do  no  hann.  h"or  permitting  rota- 
tion, it  is  necessary  to  use  forceps  such  as  the  author's  "rotation"  for- 
ceps, Fig.  3:i,  in  order  that  the  foreign  body  may  be  free  to  turn.  For 
use  with  llie  lar\iigoscoi)e  or  esophageal  speculum  the  author's  alligator 
rotation  forceps  are  used.     (Fig.  :ilO.) 


2"-i  MECHANICAL  PROBLEMS  01'  FOREIGN  BODY  EXTRACTION. 

When  the  forceps  have  slipped  off  a  foreign  body  during  attempted 
extraction,  the  bronchoscope  has  usually  been  slightly  withdrawn.  At 
this  point  extreme  caution  is  necessary.  The  first  thing  to  remember  is 
never  to  push  the  bronchoscope  immediately  downward  again.  On  the 
contrary,  it  should  be  withdrawn  a  centimeter  or  two.  Then  the  secre- 
tions and  blood,  if  any,  should  be  carefully  sponged  away  and  a  good 
clear  view  of  the  tracheal  or  bronchial  lumen  obtained.  Then,  being 
sure  the  foreign  body  is  not  being  overridden,  the  bronchoscope  is  slow- 
ly advanced  and  each  step  of  the  way  is  searched  until  the  old  location  is 
reached.  If  the  bronchoscopist  were  hastily  to  push  the  bronchoscope  down 
to  the  place  where  the  foreign  body  was  previously  seized,  the  foreign 
body  might  easily  be  overridden,  its  point,  if  any,  caused  to  puncture  or 
to  enter  a  lateral  branch,  or  it  might  be  lost  in  the  secretions  requiring 
prolonged  search.  Precipitate  grabbing  with  the  forceps  never  accom- 
plishes anything  and  may  do  serious  and  even  fatal  damage.  It  is  well 
to  see  that  the  thumb  nut  of  the  forceps  is  in  place,  and  to  look  carefully 
to  the  angle  of  closure  of  the  forceps,  to  make  sure  that  they  grip  prop- 
erly.   The  proper  closure  is  illustrated  in  Fig.  ol. 

Lateral  movements  of  the  forceps  by  the  author's  method.  In  mak- 
ing lateral  movements  of  forceps,  the  tube  mouth,  either  the  lip  or  the 
short  side,  is  used,  as  required.  The  bronchoscope  is  swung  in  the  re- 
quired direction  as  a  lever  on  its  fulcrum  (Fig.  13.5)  carrying  the  distal 
end  of  the  forceps  strongly  sidewise.  This  maneuver,  devised  by  the 
author,  has  been  exceedingly  successful,  and  has  led  him  to  wonder  at 
the  statements  made  that  lateral  movements  of  forceps  are  impossible. 
In  combination  with  the  side  curved  forceps  (Fig.  2!')  some  otherwise 
difficult  maneuvers  become  easy. 

Briughig  the  foreign  body  throiu/h  tlie  glottis.  Stripping  of  the  for- 
eign body  from  the  forceps  at  the  glottis  in  cases  where  tube,  foreign 
body  and  forceps  are  withdrawn  together,  is  so  frequently  reported  that 
it  deserves  special  consideration.  This  accident  is  due  to  one  of  four 
causes : 

1.  The  foreign  body  was  not  being  brought  out  with  its  largest 
diameter  in  the  sagittal  plane  of  the  glottic  chink. 

2.  The  forceps  w-ere  not  most  advantageously  applied. 
'■'.     The  forceps  were  mechanically  imperfect. 

4.  The  foreign  body  was  not  kept  close  up  to  the  tube  mouth,  thus 
allowing  the  glottic  tissues  to  close  tightly  on  the  forceps  between  the 
tube  mouth  and  the  intruder. 

The  remedies  are  obvious  in  each  class  of  case,  except  in  class  2. 
To  make  sure  of  proper  grasp  accurate  closure  of  the  forceps  under 
ocular  control  is  the  greatest  safeguard.     In  a<l<Iiti()n,  however,  it  is  well 


MKCUAMCAl,   rKOIM.KWS  OF  I'OUIirCN  BODY  KXTRACTlON.  37.') 

to  test  the  firmness  of  grasji  of  the  forceps  against  the  end  of  the  tube 
before  starting  to  withdraw  forceps,  tube  and  foreign  body  all  together, 
because  if  the  grasp  is  insufficient,  it  is  better  to  know  it  before  with- 
drawal is  attempted  than  to  have  the  intruder  become  wedged  in  the 
glottis,  or  to  lose  it  back  in  the  trachea.  In  the  case  of  small  objects,  if 
scraped  oiif  by  the  glottis,  they  may  drop  back  into  a  new  location  where 
removal  and  finding  may  be  still  more  difficult.  For  these  reasons,  it  is 
best  to  assure  one's  self  that  the  grasp  is  firm  before  the  foreign  body  is 
removed  from  the  locality  in  which  it  is  found.  As  a  rule,  it  is  unsafe 
to  attempt  to  test  the  grip  of  \ery  soft  friable  bodies  by  withdrawing 
them  against  the  end  of  the  tube,  except  with  the  utmost  gentleness,  be- 
cause of  the  likelihood  of  crusiiing.  When  a  foreign  body  is  strijiped  ofif 
the  forceps  on  withdrawal  it  ma\  Ijecome  jammed  in  the  glottis  in  such 
a  way  as  to  occlude  breathing  comjiletely.  It  is  therefore  wise  to  have 
always  at  hand  the  alligator  jawed  forcejjs  which  can  be  used  promptly 
through  the  direct  laryngoscope.  In  the  event  of  the  foreign  body  not 
being  of  such  shape  as  to  occlude  the  glottis  this  method  of  removal  will 
be  the  most  convenient  anyway  and  as  jiointed  out  by  D.  R.  I'aterson, 
the  circumstance  may  be  e\en  furtunate  in  pre\enting  the  loss  of  the 
foreign  body  downward.  Nevertheless,  it  will  require  prompt  action  in 
some  cases  to  avert  disaster.  The  accident  of  stripping  oft  the  foreign 
body  at  the  glottis  often  makes  the  situation  much  more  complicated  by 
the  large  quantity  of  pus  and  secretions  that  are  liberated  bv  the  loosen- 
ing of  the  foreign  body,  which  had  been  occluding  the  bronchus.  In  such 
case,  a  careful  removal  of  the  secretion  by  "sponge  pumping"  as  men- 
tioned under  ".Xsijirators"  is  necessary.  Then  careful  search  is  resumed. 
Usually  the  foreign  body  will  be  found  not  to  have  gone  so  deeply.  If 
large,  it  may  stop  at  the  bifurcation,  c\cn  though  it  had  previously  been 
nuuli  lower.  .Most  foreign  bodies  require  time  to  work  their  wav  down- 
ward. Care  must  be  used  not  to  override  the  intruder  as  explained  in 
connection  with  "Use  of  the  forceps."  The  accident  of  dropping  from 
the  grasp  of  the  forcc])s  during  process  of  broncboscopic  removal  seems 
from  the  literature  to  have  iieen  (|uite  a  fre(|uent  accident  and  in  some 
instances  it  has  ])roven  fatal.  <  )ften  the  foreign  body  will  be  found  to 
ha\e  dropped  into  the  o]i])osile  bronchus  from  tiiat  in  wlncli  it  was  first 
lodged,  the  reason  iieing  probably,  that  the  negati\e  |)ressnre  is  very  much 
less  in  the  bronchus  of  the  first  itnaded  lung  because  secretions  have  ac- 
runuilated  and  in  cases  of  long  standing  there  may  be  obliteration  of  a 
large  amount  (jf  lung  tissue,  whereas  the  negative  pressure  is  increased 
by  the  compensatory  activity  of  the  sound  side.  To  prevent  this  drop- 
]iing  into  the  main  ijronclnis  of  the  opposite  side,  r.ninings  has  suggestCkl 
the  use  of  .'i  "broiu'hus  |)rotector"  which  is  like  a  bottle  briislt.     It  is  in- 


376  MECHANICAL  PROBLEJIS  OF  FOREIGN'   BODY  EXTRACTION. 

serted  into  the  sound  bronchus  before  attempting  the  removal  of  the  for- 
eign body  from  tlie  invaded  bronchus.  Its  brush-like  form  permits  of 
respiration  but  will  prevent  the  entrance  of  a  foreign  body  of  any 
appreciable  size.  Hinsberg  reports  an  interesting  case  in  which 
a  plum  stone  in  process  of  removal  from  the  right  bronchus 
slipped  from  the  forceps  and  dropped  into  the  left  bronchus  from  which 
he  could  not  remo\e  it.  The  patient  died  within  a  few  hours.  It 
was  found  at  autopsv  that  the  right  lung  was  atrophied,  the  patient  hav- 
ing existed  almost  solely  on  the  left  lung,  the  use  of  which  was  suddenly 
lost  when  it  was  occluded  by  the  falling  backward  of  the  foreign  body. 
Ingals  (Bib.  22^)  reports  two  cases  in  which  the  foreign  body  in  process 
of  bronchoscopic  removal  slipped  from  the  forceps  and  prolonged  search 
in  the  trachea  and  bronchi  failed  to  find  it.  The  search  was  given  up 
and  the  bronchoscope  withdrawn.  In  one  of  the  cases  after  withdrawal 
the  foreign  body  was  found  in  the  patient's  mouth  and  in  the  other  case 
it  fell  out  on  the  floor.  This  points  a  very  valuable  lesson  that  should  al- 
ways be  borne  in  mind.  After  a  foreign  body  has  slipped  from  the  for- 
ceps seemingly  at  the  glottis,  on  withdrawal  of  the  bronchoscope,  forceps 
and  foreign  body  all  together,  it  must  be  remembered  that  there  is  a  pos- 
sibility that  it  really  came  through  the  glottis  and  m;u'  be  in  the  pharynx 
or  perhaps  swallowed.  This,  however,  must  not  prevent  us  from  ])rompt 
reinsertion  of  the  bronchoscope  especially  with  foreign  bodies  which  may 
cause  dyspnea,  but  if  a  preliminary  search  fails  to  find  the  foreign  body 
in  the  trachea  or  bronchi  very  careful  search  of  the  pharynx  should  be 
made  with  the  finger  and  if  the  bronchoscopy  has  already  lasted  a  con- 
siderable time  it  is  better  to  desist  and  have  another  radiograph  taken 
because  the  foreign  body  may  have  been  swallowed. 

Extraction  of  pins,  needles  and  similar  long  pointed  objects.  In  case 
of  such  bodies  as  pins,  tacks,  nails  and  the  like,  whose  points  are  pre- 
senting and  thus  the  mechanical  problem  clearly  apparent,  we  may  pro- 
ceed at  once  to  raise  the  point  with  the  lip  of  the  bronchoscope  so  as  to 
get  the  point  into  the  lumen.  It  is  usually  better  that  the  forceps  be  not 
used  to  seize  the  point  until  the  point  is  in  the  lumen,  as  otherwise  the  in- 
truder will  almost  certainly  get  crosswise  of  the  tube  mouth.  For  the 
same  reason  a  pin,  needle  or  similar  object  must  be  first  studied  from  a 
distance  lest  the  tube  mouth  override  the  proximal  end  of  the  [lin.  In 
other  words  the  nearest  end  must  be  searched  for  first,  and  the  rule 
should  be  to  look,  not  for  a  pin,  but  for  the  point  of  a  pin.  One  pull 
with  the  forceps  on  the  middle  portion  of  a  ])in  has  caused  the  point  to 
[perforate,  enormously  increasing  the  difficulties  of  removal  and  in  some 
instances  resulting  fatally.  (Fig.  177.)  Even  if  grasped  near  the  point, 
if  the  grasp  is  exactly  "on  end"  there  is  a  strong  tendency  for  the  point 


MKCHAXICAI,   rUORLI'MS  OF  FOREIGN  BODY  EXTRACTION. 


277 


of  a  pin  to  hook  over  the  mitsiilc  uf  the  tube  mouth.  In  such  a  case,  as 
soon  as  the  forceps  gras])  the  pin,  the  pin  should  be  pushed  downwarti,  if 
necessary  to   free  its  point,  or  if  this  is  unnecessary,  the  tube  can  be 


slightly   withdrawn   so   that   the  i)oint  will  not  become  hookec 


:r  the 


edge  of  the  tube  in  witiidrawal.  To  still  further  prevent  this  hooking 
over  the  edge,  it  is  often  necessary  to  move  the  lip  of  the  tube  mouth 
rather  strongly  in  the  direction  of  the  point.  The  author  usuall)'  |)rcfers 
the  pushing  downward  of  the  pin  with  the  forceps  to  disengage  it,  when 
safely  possible ;  but  it  may  be  disengaged  by  putting  a  hook  below  the 
place  where  the  point  disappears  into  the  mucosa  and  by  withdrawal  up- 
ward the  point  can  be  forced  out.      (Fig.  ITS.)      This,  of  course,  is  not 

M 


0 


0 


s 

Fig.  177.  .Schema  illustrating  one  phase  of  the  error  of  graspin.i;  a  long  for- 
eign body  in  the  middle,  upon  first  seeing  it  across  the  tube  mouth  as  at  M.  It 
gets  crosswise  of  the  tube  mouth,  like  a  "toggle  and  ring,"  and  the  point  cannot 
be  drawn  into  tnl)c  moiilh  for  protection. 


I)erniissible  if  the  jKiint  is  deeplv  embedded.  For  the  grasping  and  with- 
drawal of  pins  the  side-curved  forceps  (Fig.  2'))  are  admirably  adapted. 
The  side  curve  enabling  a  grasp  sidewise  when  the  pin  is  lying  in  contact 
with  one  bronchial  wall  as  it  usually  is.  They  can  also  be  used  closed  as 
a  hook.  I'ins,  esjjecially  the  glass-headed  steel  pins  in  common  use,  are 
very  prone  to  droj)  down  into  the  smaller  bronchi  and  to  disappear  com- 
pletely from  the  ordinary  field  of  endosco]:)ic  ex]5loralion.  Pins  with 
slightly  larger  iieads  not  dropping  so  deeply,  and  yet  gi'ing  into  the 
branches  of  the  stem  bronchus,  are  verv  prone  to  appear  and  disajipear 
during  endoscojiy,  in  a  way  that  makes  them,  at  times,  quite  difficult  to 
tind  and  remove.  Cough  will  throw  the  point  into  view,  but  the  point  will 
iniiut'(li;itely   recede  before   it   c;ui   be  gras])e(l   by   the   forceps.     This  a])- 


278 


MECHANICAL  PROBLK MS  ClF  FdRHlCN  BODY  EXTRACTION. 


pearance  and  recession  are  due  to  the  elasticity  of  the  bronchi,  the  up  and 
down  movement  during  respiration,  and  is  seen  at  its  greatest  degree 
during  cough.  When  the  intruder  is  found  the  depth  of  the  insertion  of 
the  bronchosco[je  must  be  maintained  by  sufficient  pressure  with  the 
thumb  and  finger  to  prevent  its  being  displaced  by  cough.  The  axis  of 
the  foreign  body  having  been  tletermined,  the  forceps  are  inserted  in  such 
position  that  the  jaws  will  open  in  the  proper  plane  for  grasping.  In  one 
of  the  author's  cases  an  assistant  pushing  upward  under  the  ribs  raised 


Wi> 


^J^ 


Fig.  178.  Illustrating  the  mechanical  problem  of  the  pin,  needle  (P),  tack  or 
nail  with  imbedded  point  (M),  and  its  solution.  If  the  forceps,  H,  is  pulled  up- 
on, the  head,  P,  beinj;  in  a  bronchus,  cannot  swing  round,  and  the  point,  M,  of  the 
pin  is  buried  still  deeper,  enormously  increasing  the  difficulties  of  removal  or 
causing  fatal  trauma.  If  instead  of  pulling  upon  the  forceps,  H,  they  are  I'lishcd 
as  shown  by  the  dart,  the  point  may  be  disengaged,  and  the  lip  of  the  broncho- 
scope may  be  slipped  under  the  disengaged  point.  If  the  pin  is  prevented  by  its 
head  from  being  pushed  downward,  the  point  may  be  extracted  by  traction  with  a 
hook  as  shown  at  B  and  C.  The  forceps,  Fig.  33,  may  be  used  instead  of  the 
hook  for  freeing  the  point.  In  either  case  the  extraction  is  then  done  with  the 
forceps,  Fig.  28,  or  preferably,  29.     (See  Fig.  179a.) 


the  lung  tissue  against  the  tube  mouth  enough  to  cause  the  point  of  a 
pin  "around  the  corner"  to  emerge.  (  Fig.  172.)  In  two  cases  the  rise  of 
the  diaphragm  in  connection  with  cough  expulsion  forced  the  lung  up- 
ward by  diaphraginatic  compression  sufiiciently  to  cause  the  pin  point  to 
emerge,  rather  firm  cotmterpressnre  being  maintained  with  the  broncho- 
scope on  the  tissues.  Tlie  forceps  were  introduced  and  the  next  emer- 
gence was  waited  for  when  the  point  was  instantly  seized  and  the  pin 
withdrawn  through  the  bronchoscope  in  both  cases.  In  one  instance,  the 
author  had  a  verv  interesting  case  in  which  a  pin  became  transfixed  across 


MECIIAXICAL  PROBLEMS  OF  FOREIGN  BODY  EXTRACTION. 


279 


tlic  lumen  of  the  bronchoscope  through  the  breathhig  aiJcrtures  and  into 
the  opposite  wall,  recjuiring  breaking  of  the  pin  by  pushing  on  the  forceps. 
The  relative  position  of  the  apertures  has  since  been  changed  to  prevent 
such  a  possibility.  Ingals  has  devised  a  very  ingenious  corkscrew-like 
instrument  which  will  bring  a  pin  into  the  corner  of  the  lumen  in  cases 
where  a  point  is  deeply  Iniried. 

In  the  bronchi,  it  may  not  be  possible  to  push  the  foreign  body  suf- 
ficiently far  down  to  disengage  the  point.  Under  such  circumstances,  if 
the  point  cannot  be  liberated  by  the  methods  already  mentioned,  the  pin 
must  be  cut  or  broken.    Casselberry  has  devised  a  very  ingenious  forceps 


0 


Fig.  179.  Schema  illustrating  a  serious  phase  of  the  error  of  hastily  seizing  a 
transfixed  pin  near  its  middle,  when  first  seen  as  at  M.  Traction  with  the  forceps 
in  the  direction  of  the  dart  in  schema  B  will  rip  open  the  esophagus  or  lironchus 
mflicting  fatal  trauma,  and  probably  the  pin  will  be  stripped  off  at  the  glottic  or 
the  cricopharyngeal  level,  respectively.  The  point  of  the  pin  must  be  disembedded 
and  Kottcn  into  the  tube  mouth  as  at  A,  to  make  forceps  traction  safe. 


t(ir  the  |)urp()se  of  ciUling  pins,  and  at  the  same  time  retaining  the  point, 
lie  fore  using,  these  forceps  should  be  tested  upon  a  pin  to  make  sure  that, 
after  cutting  the  point  can  be  held  in  the  forceps  and  not  get  lost.  In 
use  the  forceps  must  be  held  closed  after  closing  in  order  not  to  drop  the 
pin  in  three  pieces,  \ankauer  has  devised  a  method  of  dealing  with  the 
crosswise  fixed  pin  by  pulling  it  into  the  tube  of  a  combination  tube  antl 
hook  forceps,  which  seems  a  promising  though  as  yet  untested  method. 
It  is  intended  for  untempered  ])ins  which  will  bend  without  breaking. 
He  has  successfully  used  an  instrument  shaped  like  a  tack-drawer  for  ex- 
tracting the  embedded  point  of  a  tack  ;  and  this  should  be  equally  useful 
for  an  embedded  pin  poiiU. 


280 


MECHANICAI,  PROBLEMS  OF  FOREIGN  BODY  EXTRACTION. 


Extraction  of  lacks,  nails  and  large  licadcd  foreign  bodies  from  the 
tracheobronchial  tree.  Tacks  with  sharp  points  often  present  the  prob- 
lem of  the  buried  point  and  the  "toggle  and  ring"  tendency  to  hook  over 
the  tube  mouth  if  not  grasped  on  end,  which  have  been  considered  in  the 
section  on  extraction  of  pins.  In  addition,  however,  the  large  head  pre- 
sents a  special  problem  because  of  its  tendency  to  act  as  an  anchor  when 
buried  in  swollen  mucosa,  or  in  a  cicatricial  stenosis.  The  latter  con- 
dition will  be  mentioned  in  a  future  chaiiter  on  the  problems  associated 


Fig.  179a.  Schema  illustrating  the  mechanical  prol)lem  of  extracting  a  pin,  a 
large  part  of  whose  shaft  is  Iiuried  in  the  hroncliial  wall,  B.  The  pin  must  be 
pushed  downward  and  if  the  oritice  of  the  branches,  C,  D,  are  too  small  to  admit 
llie  head  of  the  pin  some  other  orifice  (as  at  A)  must  be  found  by  palpation  (not 
ijy  violent  pushing)  to  admit  the  head,  so  that  the  pin  can  be  pushed  downward 
permitting  the  point  to  emerge  (E).  The  point  is  then  manipulated  into  the  bron- 
choscopic  tube-mouth  by  means  of  co-ordinated  movements  of  the  lironchoscopic 
lip  and  the  side-curved  forceps,  as  shown  at  F. 


with  prolonged  sojourn.  The  traction  renuired  in  some  instances  raises 
the  question  as  to  how  much  traction  one  may  safely  make.  The  tracheo- 
bronchial tree,  and  with  it  the  lungs,  are  so  freely  movable  that  it  can  be 
felt  to  yield  resiliently  when  traction  is  made  on  an  "anchored"  tack.*  In 
many  such  cases,  however,  it  will  be  found  that  the  foreign  body  is  not 
properly  grasped  and  that  traction  is  being  made  more  or  less  at  an  angle, 
which  causes  the  foreign  body  to  get  more  or  less  of  a  hook-hold  on  the 

•strong  and  ill-directed  traction  has  ruptured  the  bronchu.s  and  proven  fatal 
in  a  number  of  patients  sent  in  to  the  author  in  a  dying  condition  from  mediastinal 
emphysema  or  pneumothorax,  the  tack  not  being  removed  (Fig.  179a).  In  other 
case.<!  extraction  had  been  rendered  infinitely  more  difficult  for  the  avithor  b.v  the 
mutilation  caused  by  the  injudiciou.s  traction.  Swollen  muco.sa  around  the  head 
of  the  tack  may  cause  some  resistance  to  traction. 


MECHAXICAI,   PROr.I.EMS  OF   FORKTGX  BODY  EXTRACTION. 


381 


angle  projecting  at  the  hraiK-li  bronchus.  This  is  especially  true  of  bodies 
like  the  upholsterer's  tack,  of  which  every  bronchoscopist  of  experience 
has  had  one  or  more  cases.  These  tacks  hold  like  a  "'mushroom  anchor," 
and  great  care  must  be  taken  that  traction  is  being  made  in  the  proper  di- 
rection. The  direction  of  traction  can  be  modified  by  the  position  in  which 
the  forceps  are  placed,  as  previously  described ;  and  it  can  also  be  modified 
by  the  movement  of  the  head  of  the  patient  and  the  bronchoscope  in  the 
proper  direction.  The  lip  of  the  bronchoscope  can  also  be  used  for  the 
moving  out  of  the  way  of  the  obstructing  tissues,  as  elsewhere  described, 
and  as  illustrated  in  Fig.  IT"^.  The  shortness  of  a  tack  may  per- 
mit it  to  turn  more  or  less  sideways  in  the  bronchus,  the  ]X)int  entering 


Fig.  i-g1>.  "Musliroimi  anchor"  prolilcni  of  the  upholstery  tack.  If  the  tack  has 
not  been  in  situ  more  than  a  few  weeks  the  stenosis  at  the  level  of  the  darts  is 
simply  edematous  mucosa  and  the  tack  can  be  pulled  through  with  no  more  than 
slight  mucosal  trauma,  provided  axis-traction  only  be  used.  If  the  tack  has  been 
in  situ  a  year  or  more  the  fibrous  stricture  may  need  dilatation  with  the  divulsor 
(Fig.  46).  Otherwise  traction  may  rupture  the  bronchial  wall.  The  stenotic  tissue 
in  cases  of  a  few  months'  sojourn  may  be  composed  of  granulations,  in  which  case 
a.xis-traction  will  safclv  withdraw  it. 


the  mucosa  or  a  lateral  branch.  This  jicrmits  the  head  in  some  in- 
stances to  present  its  edge  toward  the  observer.  (ireat  caution 
is  required  in  such  instances.  If  the  head  is  seized  as  at  A,  Fig.  180, 
serious  trauma  may  result  in  withdrawal,  liy  the  ripi^ing  effect  of  the 
point,  and  tlie  chances  of  its  getting  dragged  out  of  the  grip  of  the  for- 
ceps are  great.  If  it  is  grasped  by  the  stem  we  have  the  '"toggle  and 
ring''  action  against  tlie  tube  mouth  (Fig.  177),  and  unless  the  tack  is 
very  short  the  ])oint  will  cause  trauma.  The  best  method  in  the  author's 
experience  with  such  cases  is  to  push  the  presenting  edge  of  the  head 
downward  and  laterally  so  as  to  luing  up  the  point  as  far  as  possible. 
Then  a  hook  for  the  closed  side  cur\ed  forcejis)  is  inserted  under  the 
shank  as  close  to  the  ]ioint  as  [jossible  and  thus  the  |)oinl  can  be  brou.ght 
up  in  the  clear  so  that  it  can  be  seized  with  the  forceps  and  withdrawn 
into  the  tube  mouth.  If  the  head  is  too  large  to  enter,  the  point  is  thus 
protected  while  forcejis  and  bronchoscope  are  withilrawn  together. 


282 


MECHANICAL  PROBLEMS  OF  FOREIGN  BODY  EXTRACTION. 


Fa;.  179c.  Schema  illustrating  the  "mushroom  anchor"  problem  of  the  brass- 
headed  upholstery  tack.  At  A  the  tack  is  shown  with  the  head  bedded  in  swollen 
mucosa.  The  bronchoscopist,  looking  through  the  bronchoscope,  E,  considering 
himself  lucky  to  have  found  the  point  of  the  tack,  seizes  it  and  starts  to  withdraw 
it,  making  traction  as  shown  by  the  dart  in  drawing  B.  The  head  of  the  tack 
catches  below  a  chondrial  ring  and  rips  in,  tearing  its  way  through  the  bronchial 
wall  (D)  causing  death  liy  mediastinal  emphysema.  This  accident  is  still  more 
likely  to  occur  if,  as  often  happens,  the  tack-head  is  lodged  in  the  orifice  of  the 
upper  lobe  bronchus,  F.  But  if  the  bronchoscopist  swings  the  patient's  head  far 
to  the  opposite  side  and  makes  axis-traction,  as  shown  at  C,  the  head  of  the  tack 
can  be  drawn  through  the  swollen  mucosa  without  anchoring  itself  in  a  cartilage. 
Tf  necessary,  in  addition,  the  lip  of  the  bronchoscope  can  be  used  to  repress  the 
angle,  K,  and  the  swollen  mucosa,  H.  If  the  swollen  mucosa,  H,  has  been  replaced 
by  fibrous  tissue  from  many  months'  sojourn  of  the  tack,  the  stenosis  may  require 
dilatation  with  the  divulsor,  Fig.  46. 


Fin.  I79d.  Problem  of  the  upholstery  tack  with  buried  point.  If  pulled  upon, 
the  imminent  perforation  of  the  mediastinum,  as  shown  at  A,  will  be  completed,  the 
bronchus  will  be  torn  and  death  will  follow  even  if  the  tack  be  removed,  which  is 
of  doubtful  possibility.  The  proper  method  is  gently  to  close  the  side  curved  for- 
ceps on  the  shank  of  the  tack  near  the  head,  push  downward  as  shown  by  the  dart, 
in  E,  until  the  point  emerges.  Then  the  forceps  are  rotated  to  bring  the  point  of 
the  tack  away  from  the  bronchial  wall.  It  is  usually  better  at  this  stage  to  release 
the  tack  and  grasp  it  firmly  near  the  point  for  withdrawal,  D.  During  stages  A,  B 
and  C  the  tack  is  grasped  very  gently. 


MKCIIAMCAL  PROBLEMS  OF  FORKIGN  Iit)tlY  EXTRACTION. 


283 


111  makini,'  the  lateral  movements  referred  to,  the  tube  mouth  is  used 
to  push  the  forceps  sidewise,  the  bronchoscopic  lever  being  swung  on  its 
fulcrum  (Fig.  i;i.">).  Articles  of  jewelry,  such  as  stick  pins,  usually  re- 
c|uire  the  same  care  that  pertains  to  pins,  in  regard  to  getting  the  point 
safely  into  the  tube  mouth.  In  withdrawal  the  head  is  apt  to  catch  as 
mentioned  in  regard  to  tacks,  and  the  direction  of  traction  must  be  mod- 
ified accordingly.  Nails  of  any  except  the  smallest  sizes  are  easily 
found  and  usuallv  present  the  same  problems  of  extraction  as  mentioned 


Fig.  i/Oe.  Schema  illustrating  the  ''upper-Iobe-bronchus  problem."  combined 
with  the  "rr.ushroom-anchor''  prol)lem  and  the  author's  twice-successful  method  for 
their  solution.  Tlie  patient  being  recumbent,  the  bronchoscopist  looking  down  the 
ri;,'ht  main  bronchus,  M,  sees  the  point  of  the  tack  projecting  from  the  right  upper- 
lobe-bronchus,  .\.  He  seizes  the  point  with  the  side-curved  forceps;  then  slides 
down  the  bronchoscope  to  the  position  shown  dotted  at  B.  Next  he  pushes  the 
bronchoscopic  lube-mouth  downward  and  medianward,  simultaneously  moving  the 
patient's  head  to  the  right,  thus  swinging  the  bronchoscopic  lever  (Fig.  135)  on  its 
fulcnnn,  and  dragging  the  tack  downward  and  inward  out  of  its  bed,  to  the  posi- 
tion, D.  Traction,  as  shown  at  C,  will  then  safely  and  easily  withdraw  the  tack 
A  very  small  bnmclioscope  is  essential.  The  lif  of  the  bronchoscopic  tube-mouth 
must  be  used  to  pry  the  forceps  down  and  over,  and  the  lip  must  be  brought  close 
to  the  tack  just  before  the  prying-pushing  movement.     S,  right  steni-bmnchus. 


for  pins.  Thc'ir  piunls  are  usually  not  sharp  but  their  shape  renders  it 
necessary  to  iret  tlic  |  oiin  irto  the  tube  ir.oulh  to  ]ire\ent  "tog.;"e  and 
ring"  action.  The  !>ide  cur\cd  icirceps  (  Fig.  'V.>  I  usuall\  get  a  belter  hold 
than  straight  jaws,  and  they  can  be  used  to  better  advantage  in  lateral 
movements  and  in  gras])ing  pins,  nails  and  tacks.  Nails  lodged  head 
uppermost  niav  present  the  proiilem  of  annular  edema  (Fig.  182). 

Jervey  (  I'.ib.  '^Tlj,  by  a  very  ingeni(nts  mclhod.  extracted  a  very 
large  nail  by  carefully  disengaging  the  ])oint  and  getting  the  nail  into  the 
bronchoscope  for  li.ilf  the  nail's  length  and  then  pressing  ihe  nail  tightly 
to  the  wall  of  the  tube  b\-  means  of  a  hook  tirniK'  rotated. 


284 


MECHANICAL   PROBLE^!S  OF  FOREIGN  BODY  EXTRACTION. 


Hollow  iHctallic  bodies.  For  foreign  bodies  presenting  an  opening 
toward  the  observer,  no  instrument  has  proven  more  efficient  than  the 
excellent  one  of  Killian  (Bib.  Sli!),  p.  26)-  Different  endoscopists  will 
prefer  different  handles,  but  the  grooved  expansile  holder  shown,  fitted 
to  a  suitable  handle,  cannot  be  excelled  for  firmly  grasping  and  holding 
such  foreign  bodies.  An  additional  merit  is  that  most  of  such  bodies, 
when  so  held,  are  in  the  best  position  for  removal,  whereas  if  grasped  by 
their  edge  there  is  more  or  less  traumatism  apt  to  be  inflicted  bv  other 
portions  of  their  edge,  if  thin.  If  a  large  cylindrical  hollow  metallic  body 
does  not  [iresent  its  opening  toward  the  operator,  it  may  present  the 
problem  of  annular  edema,  Fig.  182.  It  may  be  turned  if  not  too  long, 
but  as  a  rule  the  method.  Fig.  182.  is  preferable. 


Fig.  i8o.  Schema  of  the  mechanical  problem  of  tack  e.xtraction  from  the 
bronchi.  If  the  edge  of  the  head  presents,  the  point  being  in  a  branch  bronchus 
or  imbedded  in  the  wall,  traction  upon  the  head  in  the  direction  of  the  dart  will 
produce  trauma  and  will  probably  be  unsuccessful,  .\fter  turning,  the  point  is 
seized  as  at  B,  and  traction  is  safe  and  successful. 


Reino'al  of  open  safety  pins  from  the  trachea  and  bronchi.  The  re- 
moval of  a  closed  safety  pin  presents  only  the  ordinary  mechanical  prob- 
lem of  the  long  foreign  body  that  must  be  grasped  on  end  to  jjrevent 
the  '"tog.gle  and  ring"  difficulty.  When  the  safety  pin  is  open,  but  with 
point  down  the  problem  is  quite  easy  of  solution.  The  near  or  spring  end 
of  the  pin  is  grasped  and  jiulled  into  the  bronchoscope  which  closes  the 
pin.  If  the  pm  cannot  be  withdrawn  completely  into  the  tube  it  must  at 
least  be  drawn  in  until  the  "keeper"  end  of  the  pin  is  close  up  against 
the  tube  mouth,  not  only  to  prevent  the  loss  of  the  pin  at  the  glottis,  but 
to  prevent  trauma  by  the  usually  sharp  and  hook-like  "keeper."  When 
we  have  to  deal  with  an  open  safety  ])in  lodged  point  up  we  have  a  difficult 
problem,  the  proper  execution  of  which  is  one  of  the  most  interesting  in 


JIKCIIAKICAI.   PKOItLF.MS  01'  FOREIGN   BODY   EXTRACTION.  285 

bronchoscoin-.  If  the  pin  is  grasped  and  pulled  out  without  closing  the 
pin.  the  point  will  inflict  severe  and  probably  fatal  trauma.  If  the  pin 
is  in  the  cervical  trachea  the  patient  will  be  subjected  to  less 
risk  in  a  removal  by  tracheotomy  than  by  a  ruthless  endo- 
scopic extraction.  If  an  experienced  and  careful  bronchoscopist  is  avail- 
able, tracheotomy  is  a  great  injustice  to  the  patient.  It  the  intruder  is  in 
the  thoracic  trachea,  tracheotomy  is  absolutely  contraindicated,  and,  more- 
over, quite  unnecessary.  The  pin  must  be  closed  and  removed  or  the 
point  must  be  protected  by  the  lip  of  the  bronchoscope,  as  shown  at  C  in 
Fig.  178  in  dealing  with  the  point  of  straight  pins.  Then  the  point  of 
the  safety  i)in  is  grasped  with  the  side  curved  forceps,  Fig.  29,  and  pulled 
into  the  bronchoscope.  This  leaves  the  "keeper"  end  out,  but  as  the  hook- 
like end  is  down  no  trauma  will  be  inflicted  in  withdrawal.  But  the  pin 
will  almost  certainly  be  lost  at  the  glottis  if  care  is  not  taken  to  be  sure 
that  the  greater  plane  of  the  keeper  corresponds  to  the  sagittal  plane  of 
the  glottis.  If  the  safety  pin  is  a  small  one  it  may  be  entirely  pulled  into 
the  bronchoscope  by  the  ffirceps  applied  to  the  point.  Large  pins  are  too 
stiff  for  this  and  rupture  of  the  bronchus  might  result  from  the  attempt. 
Closure  of  an  open  safety  pin  lodged  point  upward  is  not  a  difficult  pro- 
cedure for  those  who  will  preliminarily  practice  it.  The  author's  methoil 
is  shown  schematically  in  h'ig.  LSI.  The  most  essential  precaution  is  to 
select  frrjm  the  set  of  three  a  closer  that  has  a  ring  of  the  jiroper  size 
for  the  ])arlicular  pin  in  question.  The  ring  should  he  large  enough  to 
admit  the  s]iring  end  of  the  jiin,  but  should  be  no  larger  than  necessary. 
This  is  jjcst  determined  by  trial  with  a  similar  pin,  if  one  is  brought  1)\' 
the  patient,  or  by  trial  with  a  ])in  of  similar  size  and  shape  as  determined 
with  the  aiil  of  a  radi(jgrai)h.  Due  allowance  must  be  made  for  radio- 
graphic magnification,  if  any.  The  ring  of  the  author's  pin  closer  is  oval 
which  is  of  fundamental  imjjortance.  Many  clumsy  imperfect  models  are 
sold  under  the  author's  name.  In  case  of  an  infant  too  small  to  ad- 
mit a  bronchoscope  large  enough  to  admit  the  closer  through  the  lumen. 
the  closer  may  be  passed  into  the  trachea  first  and  allowed  to  lie  on  the 
posterior  tracheal  wall  and  interarytenoid  space  while  the  bronchoscope 
is  passed  through  the  glottis  anterior  to  the  stem  of  the  closer.  The  fork 
is  removed  after  the  pin  is  closed  and  the  removal  is  accomplished  with 
forceps.  Should  the  endoscopist,  from  insufficient  practice  or  con- 
structive imperfection  of  the  particular  instrument  at  hand,  be  unable  to 
close  the  pin  completely,  he  can  at  least  bring  the  point  away  from  the 
wall  and  then  the  pniiU  can  be  guarded  by  pushing  the  bronchoscope  down 
o\-er  it.  The  iioint  can  then  be  seized  with  forceps  if  necessary,  thougli 
it  will  nsu.ally  be  found  that  the  i)in  is  tightlv  held  bv  keeping  the  broncho- 
scope and  pin  closer  in  exact  relation  to  each  other  after  the  fork  is  re- 


286  MECHANICAL   PROBLEMS  OE  FOREIGX  BODY  EXTRACTION. 

moved.  The  author  has  had  two  cases  of  open  safety  pins  lodged  point 
ujiward  at  the  bifurcation  of  the  trachea,  one  of  which  was  removed  after 
closure  by  the  author's  method  (Fig.  181)  ;  and  the  other  was  removed 
by  pulling  the  point  into  the  bronchoscope  after  liberating  the  point  with 
the  lip  of  the  bronchoscope  and  a  hook  as  shown  at  C,  Fig.  178.  Thus 
protecting  the  point  during  removal,  the  pin,  held  by  the  point  with 
forceps,  was  withdrawn,  the  pin  being  so  turned  that  the  "keeper"  end  of 
the  pin  was  made  to  correspond  to  the  long  diameter  of  the  glottis. 
Forceps,  bronchoscope  and  pin  were  all  withdrawn  together.  Hudson 
Makuen  has  closed  an  open  safety  pin  in  the  trachea  bv  the  method  de- 
scribed above.  To  the  writer's  knowledge,  these  are  the  only  three  cases 
of  an  open  safety  pin  in  the  lower  air  passages.    A  number  have  occurred 


A _^ 


L 


Fig.  i8i.  Schema  illustrating  the  endoscopic  closure  of  open  safety  pin,5 
lodged  point  upward.  The  closer  is  passed  down  under  pcular  control  until  the 
ring,  R,  is  below  the  pin.  The  ring  is  then  erected  to  the  position  shown  dotted 
at  M,  by  moving  the  handle,  H,  downward  to  L  and  locking  it  there  with  the 
latch,  Z.  The  fork.  A,  is  then  inserted  and,  engaging  the  pin  at  the  spring  loop, 
K,  the  pin  is  pushed  into  the  ring,  thus  closing  the  pin.  Slight  rotation  of  the  pin 
with  the  forceps  may  he  necessary  to  get  the  point  into  the  keeper. 

in  the  laryn.x.     (Jpen  safety  pins  seem  to  seek  the  esophagus,  in  which 
location  the  author  has  had  fourteen  cases. 

Removal  of  fish  hooks  and  double  [•ointcd  tacks  from  the  trachea. 
These,  if  lodged  point  down  present  no  difficulties  though  they  must  be 
approached  carefully  to  avoid  causing  perforation.  If  lodged  point  up 
they  must  be  dealt  with  in  the  most  careful  manner.  The  slightest  pull 
will  complicate  the  problem  by  sinking  the  points  into  the  wall.  The  au- 
thor has  never  had  a  fish  hook  to  deal  with,  but  he  has  worked  out  a 
number  of  methods  which  will  be  inentioned  in  connection  with  eso- 
phageal foreign  body  problems.  The  author's  experience  with  the  double 
pointed  tack  and  staple  has  led  him  to  favor  turning  this  kind  of  intruder 
end  for  end  by  means  of  the  rotation  forceps.  Fig.  :i;),  or  the  full  curved 
hook  shown  at  C  in  Fig.  17S,  api>lied  to  the  far  (curved)  end  of  the  tack 
or  staple.  This  is  only  feasible  with  a  relatively  short  intruder  or  a  large 
trachea.     With  a  long  staple  in  the  infant  trachea  the  best  method  is  to 


MECIIAXJCAI.  I'KUBLK-MS  01"  l"ORIvIGN  BODY  EXTRACTION.  287 

■'coax"  the  intruder  along  gently  under  ocular  guidance,  never  making 
traction  enough  to  hury  the  point  deeply,  and  lifting  the  point  with  the 
hook  whenever  it  show^s  any  inclination  to  enter  the  wall.  This  is  not 
difiicult  to  do  in  the  trachea,  hut  extreme  dexterity  is  needed  thus  to  get 
the  intruder  through  the  glottis.  Should  the  endoscopist  fail  in  this,  or 
have  doubts  as  to  his  ability  to  accomplish  it,  he  is  justified  in  doing  a 
tracheotomy  for  removal  after,  not  before,  he  has  brought  the  intruder 
up  to  the  subglottic  region.  The  child  must  be  kept  in  the  Trendelen- 
berg  position  in  order  to  prevent  the  intruder  dropping  again  into  the 
thoracic  trachea  and  a  bronchoscope  must  be  left  in  the  glottis  during  the 
tracheotomy  to  forestall  spasmodic  stenosis.  Under  no  circumstances 
should  the  intruder  be  violently  pulled  through  the  glottis  point  first. 
Mortality  will  almost  certamly  follow.  Tracheotomy  for  the  insertion 
of  a  bronchoscope  for  the  removal  of  inverted  double  pointed  tacks  from 
the  thoracic  trachea  or  from  the  bronchi  is  a  mistake.  Better  work  can 
be  done  through  the  mouth  u])  to  the  point  of  getting  the  tack  into  the 
subglottic  region.  In  certain  locations  turning  is  facilitated  by  diverting 
the  points  into  branch  bronchi  as  in  the  case  illustrated  by  Figs.  IHla,  ISlb 
and  181c. 

The  extraction  of  tightly  fitting  foreign  bodies  from  the  bronchi. 
Annular  edema.  Bodies  ^ncli  as  corks,  jjebbles,  marbles.  Job's  tears, 
beads  anfl  the  like  are  prdiiclled  into  the  lower  air  passages  with  consid- 
erable force  by  the  insiiiratory  blast,  es])ecially  by  the  deep  inspiration 
following  cough.  This  ini])action  prevents  further  ingress  of  air,  and  the 
absorption  of  air  below  adds  a  negative  ])ressure  which  increases  the  im- 
paction and  the  tightness  of  the  fit  aids  in  quickly  producing  an  annular 
mucosal  swelling  (.\,  Fig.  182)  wdiich  covers  the  j^resenting  part  of  the 
intruder  so  that  all  that  is  seen  is  a  small  surface  in  the  center  of  an 
acute  edematous  stenosis.  If  application  of  the  forceps  (F,  Fig.  183)  is 
attempted  they  will  not  expand  sufticiently  to  take  in  the  intruder  be- 
cause of  the  annular  edema  .\.  The  author  in  such  cases  uses  a  forceps 
(K)  having  very  stiff  expansive  spring  jaws  so  that  when  protruded 
from  the  forceps  cannula  they  will  expand  with  sufficient  force  to  press 
out  of  the  way  (in  the  plane  of  their  own  expansion  only,  not  annularly), 
the  swollen  mucosa  so  as  to  permit  of  seizure  of  the  foreign  body,  as 
shown  at  B.  The  jaws  of  these  forceps  are  narrow,  because  it  is  easier 
to  press  outward  a  narrow  portion  of  the  swollen  mucosa  than  a  wide 
one.  Of  course  the  jaws  must  not  be  so  narrow  as  to  cut,  and  in  using 
the  forceps  it  is  necessary  to  use  great  care  to  prevent  damage.  .\11  use 
of  such  instriiments  must  be  under  the  guidance  of  the  eye.  .\nother 
very  effectual  way  (big.  18:'))  is  to  repress  the  swollen  mucosa  at  one 
point   with   liu-  lip  of  the  bronchoscope  so   that   a   hook   may   be  jiassed 


288 


MECHANICAL   PROIU.KMS  OF  FOREIGN   BODY  EXTRACTION. 


Fig.  iSia.  Radiographs,  anteroposterior  and  lateral  showing  a  staple  in  a  posterior 
hranch  of  the  inferior-lobe  bronchus,  lO  centimeters  (4  inches)  below  the  bifurcation 
of  the  trachea,  in  a  man  aged  44  years.  (Plates  made  by  Dr.  George  W.  Grier. 
Author's  case.) 


Mi:ciI.\.\K'AI.  I'Kdlll.KMSOF  I"()RF,IGi\  BODY  EXTRACTION. 


289 


below  the  intruder  w  liich  is  drawn  upward  to  a  wider  place  where  the 
forceps  can  be  appHed,  or  in  some  instances  it  can  be  imprisoned  against 
the  tube  mouth.  One  of  the  most  difficult  mechanical  problems  is  w-here 
a  foreign  body  that  completely  occludes  a  bronchus  into  which  it  is  tightly 
drawn  bv  the  absorption  of  air  below,  and  that  in  addition  has  a  conoidal 


Fic.  iXili.  Schema  illu'itratiiig  a  new  method  of  removal  of  broiicliially-lodged 
staples  or  double-pointed  tacks.  H,  bronchoscope.  A,  swollen  mucosa  coverin;; 
points  of  staple.  At  E  the  staple  has  been  manipnlated  upward  with  bronchoscopic 
lip  and  hooks  until  the  points  are  opposite  the  branch  bronchial  orifices,  B,  C. 
Traction  beins  made  in  the  direction  of  the  dart  (F),  by  means  of  the  rotation 
forceps,  and  counterpressure  being  made  with  the  bronchoscopic  lip  on  the  points 
of  the  staple,  the  points  enter  the  branch  bronchi  and  permit  the  staple  to  be  turned 
over  and  removed  willi  points  trailing  harmlessly  behind  (K). 


Fk;.  i8ic.  Staph-  (actual  ^izc  I  removed  from  tlie  right  lung  (see  Fig.  i8ia), 
bloodlessly  through  tlie  moutli,  by  bronchoscopy,  after  version  as  shown  in  Fig. 
i8ib. 


fiinn  towanl  the  operator.  The  iirobleni  is  diliicult,  especially  if  the  in- 
truder is  hard  and  smooth  because  the  forceps  cannot  get  a  large  surface 
of  contact  and  hence  slip.  I'atience.  however,  will  succeed.  Eventually 
a  sufficiently  tight  Imlcl  w  ill  In-  niainlaiued  lu  withdraw  the  foreign  body. 
notwilh^taiiiling   the    iieg.itixe   pressure    which   has   ]Hilled   it    down   and 


290  iMECHANICAL  PROBLEMS  OF  FOREIGN  BODY  EXTRACTION. 

which  is  still  resisting  its  withdrawal.  The  author's  heavier  forceps  are 
used  for  this  because  tactile  sensibility  is  not  so  essential  as  in  friable 
bodies.  Strong  forceps  are  needed,  not  for  traction  but  for  firm  holding 
on  a  hard  smooth  surface  of  a  presenting  cone.  An  illustrative  case  of 
the  author  is  the  lump  of  coal  removed  from  the  bronchus  of  a  Mara- 
thon racer  (see  Chapter  XXI).  In  the  case  of  a  rubber  pencil  eraser 
Richardson  (Bib.  448)  used  a  screw-pointed  instrument  which  he  screwed 
into  the  rubber  as  one  would  a  corkscrew.  Such  a  procedure,  of 
course,  requires  great  care  and  skill.  In  some  instances,  the  largest  pos- 
sible tube  that  would  enter  the  bronchus  without  injury,  has  been  used  to 
liberate  the  foreign  body.  In  some  such  instances  the  intruder  has  been 
coughed  into  the  tube.     Such  cases  have  been  reported  by  Tilley   (Bib. 


Fig.  182.  Schema  illustrating  the  problem  of  a  tightly  impacted  foreign  body 
(C),  above  which  an  annular  edema  (A)  prevents  sufficient  e.xpansion  of  the  for- 
ceps, F.  Pushing  on  the  forceps  may  force  the  foreign  body  into  the  mediastinum 
or  pleura.  A  special  forceps  (L)  with  very  narrow  and  stiff-springed  expansile 
jaws  (K)  is  used  to  displace  the  edematous  mucosa  (in  the  plane  of  their  ex- 
pansion only)  as  at  B,  so  that  they  can  be  pushed  down  over  the  foreign  body 
sufficiently  for  a  good  grip  on  the  foreign  body  (D). 

546),  Geo.  L.  Richards,  Beck  and  others.  As  pointed  out  by  Ingals 
(Bib.  22G)  oversized  tubes  must  be  used  with  caution,  and  this  may 
be  said  of  every  endoscopic  procedure.  A  very  interesting  and  quite 
unique  case  of  the  aid  of  gravity  in  bronchoscopic  foreign  body  extrac- 
tion is  that  of  Goldstein  (Bib.  185)  in  which  by  placing  the  child  in  the 
Trendelenberg  position  a  marble  after  disimpaction  was  skillfully 
dragged  down  hill  with  a  bent  bronchoscopic  probe. 

Extraction  of  soft  friable  bodies  from  the  tracheo-bronchial  tree. 
Bodies  that  are  soft,  either  by  nature  or  from  maceration  in  the  secre- 
tions of  the  tracheobronchial  tree,  besides  the  difficulty  of  disimpaction 
present  the  difficulty  of  removal  without  crushing  and  permitting  the  frag- 
ments to  scatter.  The  essentials  for  successfully  dealing  with  this  prob- 
lem are  extremely  delicate  forceps  unopposed  by  springs  and  a  well  de- 
veloped sense  of  touch  on  the  part  of  the  operator.     As  elsewhere  men- 


JIKCHANICAL  PK'IBLKMS  dl"  FOREIGN   liODV  EXTRACTION. 


291 


tioned,  heavy  spring  opposed  foiccps  prevent  all  delicacy  of  touch  and 
manipulation.  The  form  of  jaws  used  in  Killian"s  "bean"  forceps 
Fig.  32  is  very  useful  in  the  removal  of  friable  bodies  and  the  author 
uses  jaws  modeled  after  these  adapted  to  his  forceps.  In  the  removal  of 
friable  foreign  bodies,  if  they  are  by  accident  broken  up  bv  too  firm  a 
grasp  of  the  forceps,  the  question  will  arise  how  long  the  search  should 
be  continued  for  every  minute  fragment.  As  a  rule,  fragments  smaller 
than  2  mm.  in  diameter  have  a  very  good  chance  of  being  coughed  up 
with  the  secretions  which  surround  them.  In  some  instances,  howe\er, 
foreign  bodies  of  this  size  and  smaller  will  cause  multii)lc  abscesses,  so 
that,  as  a  rule,  the  bronchoscopist  should  jiersist  in  his  search  until  he 


Fig.  183.  Schema  illustrating  the  use  of  the  lip  of  the  bronchoscope  in  disini- 
paction  of  foreign  bodies.  A  and  B  show  an  annular  edema  above  the  foreign 
body,  F.  At  C  the  edematous  mucosa  is  being  repressed  by  the  lip  of  the  tube- 
mouth,  permitting  insinuation  of  the  hook,  H,  past  one  side  of  the  foreign  body, 
which  is  then  withdrawn  to  a  convenient  place  for  application  of  the  forceps. 
This  repression  by  the  lip  is  often  used  for  purposes  other  tlian  the  insertion  of 
hooks.     The  lip  of  the  esophagoscopc  can  he  used  in  the  same  way. 


has  removed  every  fragment  that  he  can  find.  Dottbtless  quite  a  large 
quantity  of  small  particles  of  friable  foreign  bodies,  such  as  jieanuts,  will 
be  removed  along  with  secretion  by  the  author's  "sponge  pumping'' 
method  elsewhere  described  for  the  remoxal  of  secretions  willmut  an 
aspirator.  The  sponges  and  secretions  should  be  saved  and  washed  to 
find  the  jiarticles  after  bronchosco])y.  .Veither  the  occasional  success  of 
this  nor  the  chance  of  a  foreign  bod\-  being  coughed  uj)  shoidd.  however, 
make  one  feel  warranted  in  flelibcrately  breaking  a  friable  foreign  body, 
which  cannot  be  considered  as  otherwise  than  a  disaster.  Claw  forceps 
are  particularly  un<lesirablc  and  beans  should  always  be  seized  with  the 
plain  foreign  body  forceps  or  "beau  forceps"  of  delicate  construction.  By 
delicate  pressure  with  these,  crushing  can  be  avoided,  whereas  with  claw 
forceps  the  ])erforation  of  the  claws  is  almost  certain  to  cause  the  break- 
ing up  of  tile  intruder.     In  dealing  with  soft  friable  bodies  of  round  shape 


292  MECHANICAL  PROBLEMS  OF  FOREIGN  BODY  EXTRACTION. 

of  which  the  swollen  mucosa  overlaps  the  presenting  end  the  stiff-springed 
forceps  above  described  cannot  be  used  with  sufficient  delicacy  and  the 
points  would  comminute  the  intruder.  The  tube  mouth  must  be  placed 
in  gentle  contact  with  the  foreign  body  and  then  moved  laterally  so  that 
the  lip  of  the  bronchoscope  will  draw  aside  a  little  crevice  between  the 
intruder  and  the  bronchial  wall,  in  order  that  a  hook  may  be  inserted  at 
one  side  of  the  foreign  body,  which  is,  by  means  of  the  hook,  withdrawn 
to  a  wider  place  in  the  bronchial  lumen  where  the  delicate  forceps  jaws 
(Fig.  183)  can  be,  when  fully  expanded,  closed  over  the  foreign  body. 
The  mechanical  spoon  (Fig.  40)  is  substituted  for  a  hook,  if  the  intruder 
is  in  the  main  bronchus  of  an  adult.  Unless  the  swelling  of  the  bronchial 
mucosa,  and  also  of  the  bean  or  similar  absorbent  foreign  bodv  is  very" 
great,  the  author  has  usually  found  it  possible  to  use  forceps  in  the  ex- 
traction of  the  foreign  body  ;  but  the  manipulation  must  be  extremely  del- 
icate, otherwise  the  intruder  will  be  crushed  and  its  fragments  scattered. 
The  distance  of  the  tube  mouth  during  such  manipulations  is  necessarily, 
at  the  beginning,  close  to  the  foreign  body.  \\  hen  the  mechanical  spoon, 
the  hook  or  the  forceps  are  properly  placed,  the  tube  must  be  withdrawn 
ahead  of  the  foreign  body  as  the  latter  is  brought  upward,  unless  it  is 
desired  that  the  foreign  body  shall  enter  the  tube.  Holding  of  large  soft 
intruders  tightly  against  the  tube  mouth  cannot  be  done  in  case  of  very 
friable  foreign  bodies  without  risk  of  crushing  them.  It  is  feasible  in  the 
less  friable  bodies.  Herbert  Tilley  reports  (Bib.  o-46)  the  bronchoscopic 
removal  of  a  green  pea  from  the  right  bronchus  of  a  man  aged  63  under 
local  anesthesia,  by  a  verv  ingenious  method.  The  bronchoscope  was 
passed  down  to  the  pea  against  which  it  was  firmly  pressed.  A  closely 
fitting  plug  of  cotton  wool  soaked  in  liquid  paraffin  ( petrolatum  )  was 
passed  down  the  bronchoscope  until  it  reached  the  foreign  body.  Then 
by  a  sudden  but  sharp  movement  of  withdrawal  of  the  piston-plug  the 
I)ea  was  sucked  into  the  lower  end  of  the  bronchoscope  and  removed  to- 
gether with  the  tube.  Winslow  (Bib.  jT-") )  reports  the  recovery  of  a 
desperate  case  after  the  bronchoscopic  removal  of  the  pulp  of  an  almond 
from  the  left  bronchus  of  a  child  two  years  of  age.  Friable  bodies  such 
as  egg  shells  and  thin  glass,  of  each  of  which  the  author  has  had  cases. 
require  an  extremely  delicate  touch,  for  which  the  extremely  delicate 
forceps  are  necessary. 

Removal  of  small  animal  objects  from  the  trachco-hronchial  tree. 
The  author  has  never  had  occasion  to  remove  an  insect.  Flies  and  small 
beetles  are  occasionally  inhaled ;  but  are  usually  promptly  coughed  out. 
Leeches  seem  to  be  of  not  rare  endoscopic  occurrence  in  Europe.  Sarg- 
non,  Guisez  and  others  have  reported  cases.  Masterman,  quoted  by 
Sir  St.  Clair  Thomson   (Bib.  539)  states  that  a  ten  or  twenty  per  cent 


MKCHAMCAL  PKiJULE-MS  OF  FOREIGN"  BODY  EXTRACTION.  ;20:! 

solution  of  cocaine  will  cause  a  leech  to  loosen  its  hold  from  paralysis. 
Doubtless  ascarides  and  other  living  parasites  would  be  equally  suscep- 
tible. In  grasping  any  form  of  animal  tissue  the  plain  foreign  body  for- 
ceps (Fig.  SS  I  or  the  side  curved  forcej^s  (  Fig.  'i'-i  I  are  best.  The  broad 
surface  will  hold  without  comminuting  the  intruder. 

Extraction  of  foreign  bodies  from  the  ttppcr-lobc  bronchus  presents 
interesting  problems  because  of  the  impossibility  of  obtaining  a  lumen 
presentation.  Fortunately,  it  is  exceedingly  rare  for  foreign  bodies  to 
disappear  wholly  into  the  upper-lobe  bronchus.  (If  the  author's  six  cases 
all  but  one  had  been  pushed  there  by  previous  operators.  If  a  portion  of 
the  foreign  body  projects  the  intruder  can  be  removed  by  the  method 
shown  in  Fig.  ]79e.  A  foreign  body  that  has  disappeared  completely 
within  the  upper-lobe  bronchus  can  be  removed  liv  the  author's  upper-lobe- 


Fic.  18.3a.  The  aiitlior's  iipper-lolje  bronchus  forceps  for  reaching  "around  tlie 
corner"  in  the  bronchoscopic  extraction  of  foreign  bodies.  The  jaws,  B,  can  be 
straightened  out  in  passing  them  through  the  bronchoscope  but  will  spring  back  into 
their  original  shape  on  emerging  at  the  distal  bronchoscopic  tube  mouth.  The  end 
of  the  forceps  cannula,  .\,  is  a  spiral  tube  so  as  to  pass  over  the  curved  jaws  as 
shown  at  C. 

bronchus  forceps  (  l-'igs.  18:ia,  l.s;Jb,  LSMcj  guided  by  the  collaboration 
with  a  fluorcscopist  looking  through  the  double-plane  fluoroscope  devised 
for  the  author  by  Dr.  George  W.  drier. 

KUI.ES   FOR  ENDOSCOPIC   FOREICN    BODY    EXTRACTION. 

].  Never  endoscope  a  foreign  body  case  un]ircpared,  with  the  idea 
of  taking  a  preliminary  look. 

3.  -Aijproach  carefullv  tlic  >usiicctcil  location  of  a  foreign  body,  so 
as  not  to  override  any  portion  of  it. 

•"1.     .\void  grasping  a  foreign  body  haslil\-  as  soon  as  seen. 

4.  The  shape,  size  and  ])osition  of  a  foreign  body  and  its  relatimis 
to  surrounding  structures  siiould  be  studied  before  attemiiting  to  ajiply 
the  force|)s.     (  l'"\ception  cited  in  Rule  in.) 

5.  1 'rcliniin.-iry  study  of  a  foreign  body  sboubl  be  from  a  distance. 
•  1.     The  tirst  grasp  of  the  forceps  being  the  best,  it  sliould  be  well 

planned  beforehand  so  as  to  seize  the  proper  ])art  of  the  intruder. 

7.  \\  ith  all  long  foreign  bodies  the  motto  should  be  "Search,  not 
for  the  foreign  bodv,  but   for  its  nearer  end."     With  pins,  needles  and 


294 


MECHANICAL  PROBLEMS  OF  FOREIGN'  BODY  EXTRACTION. 


Fig.  18.3b.  Schematic  illustration  of  the  author's  upper-lobe-bronchus  forceps  in 
position  grasping  a  pin  in  an  anteriorly  ascending  branch  of  the  upper-lobe  bronchus. 
1",  trachea;  UL,  upper-lobe  bronchus;  LB,  left  bronchus;  SB,  stem  bronchus. 


Fig.  183c.  Upper-lobe-bronchus  forceps  in  position  in  the  living  patient. 
Radiograph  originally  made  for  localization,  but  incidentally  showing  curve  re- 
sumed on  forceps  after  emerging  from  the  bronchoscope. 


MKCIIANICAI,  1'KI)1U.1'MS  01*  FOREICX  BODY  EXTRACTION.  295 

the  like,  with  pdim  upward,  search  always  for  the  point.     Try  to  see  it 
first. 

8.  Rememhcr  that  a  lung  foreign  body  grasped  near  the  middle 
becomes,  mechanically  speaking,  a  ''toggle  and  ring." 

9.  Remember  that  the  mortality  to  follow  failure  to  remove  a  for- 
eign body  does  not  justify  probably  fatal  violence  in  removal. 

10.  Laryngeallv  lodged  foreign  bodies,  because  of  the  likelihood 
of  dislodgement  and  loss  may  be  seized  by  any  part  first  presented,  and 
plan  of  withdrawal  determined  afterward. 

1 1 .  For  similar  reasons  laryngeal  cases  should  be  dealt  with  only 
in  the  author's  position,  (Fig.  73a). 

12.  An  esophagoscopy  may  be  needed  in  a  bronchoscopic  case,  or 
a  bronchoscopy  in  an  esophageal  case.  Both  kinds  of  tubes  should  be 
sterile  and  ready  in  every  case  before  starting.  It  is  the  unexpected  that 
hajjpens  in  foreign  body  endoscopy. 

13.  Do  not  pull  on  a  foreign  body  unless  it  is  properly  grasped  to 
come  away  readily  without  trauma.     Then  do  not  pull  hard. 

14.  Do  no  harm,  if  you  cannot  remove  the  foreign  body. 

Fluoroscopic  bronchoscopy.  In  cases  of  foreign  bodies  which  can- 
not be  found  bronchoscopically.  and  yet  which  show  clearly  in  the  ray. 
the  bronchoscope  may  be  ])assed  to  the  suspected  region  and  a  probe  may 
be  passed  into  a  bronchus  too  small  for  the  bronchoscope  to  enter.  If 
the  body  is  of  such  density  as  to  show  in  the  fluoroscopic  screen,  the 
fluoroscopist  can  give  a  promjit  answer  as  to  the  localization,  and  this 
will  lie  especially  valuable  if  IkuIi  a  horizontal  and  a  vertical  screen  can 
be  used.*  Such  a  combination  of  screens  would  be  valuable  for  fluoro- 
scopic aid  in  the  guiding  of  forceps  for  the  removal  of  foreign  bodies 
located  in  such  small  peripheral  bronchi  that  the  intruder  could  not  be 
seen  endoscopically.  Personally,  however,  the  author  questions  the  ad- 
visability of  closing  forceps  by  an\-  other  means  than  by  the  endoscopic 
guidance  of  the  eye.  It  happens  only  rarely  that  the  foreign  body  is 
visible  on  the  fluoroscopic  screen.  When  not  visible  fluoroscopically,  a 
radiograph  should  be  taken  with  the  probe  in  situ.  Having  limited  by 
the  means  previously  mentioned,  the  number  of  bronchi  to  be  searched, 
the  endoscopist  can  usually  memorize  two  or  three  bronchi  for  separate 
exposure,  and  by  remembering  the  place  it  is  possible  to  tell  which  one 
of  the  bronchi  is  invaded.  The  Ijest  probe  for  this  purpose,  in  the  au- 
thor's experience,  is  the  very  small  forceps  which  are  only  half  the  size 
of  the  regular  forceps.     They  are  used  closed  which  gives  a  very  safe 

•Di-  I'leorRc  \V.  Giitr  has  ilevi.ii>(I  for  the  author  a  double-plane  fluoroscope 
that  promi.xt'.-'  to  be  very  u.sc-tul  in  oases  of  foreien  bodies  that  are  in  .xucli  minute 
bronchi  tliat  thev  cannot  be  found,  and  In  cases  of  upper-lobe  lironchu.-s  invasion 
provided  the  intruder  is  dense  to  the  ray.  General  anesthesia  should  not  lie  used 
l)ecause  of  the  inllamniability  of  ether  and  because  the  patient  should  liold  his 
breath  at  command. 


296  MECHANICAL  PROBLEMS  OE  FDREIGN  BODY  EXTRACTION. 

probe  pointed  instrument,  and  if  the  intruder  is  found  it  can  at  once  be 
seized.  If  not  found  the  forceps  will  show  in  a  radiograph.  The  au- 
thor has  had  two  cases  in  which  extraction  of  bronchially  lodged  foreign 
bodies  was  previously  tried  by  other  endoscopists.  Both  were  foreign 
bodies  of  moderate  size  lodged  in  the  right  stem  bronchus  and  not  diffi- 
cult of  removal.  In  one  case  fluoroscopic  bronchoscopy  had  been  un- 
successfully tried  for  over  an  hour  under  ether  anesthesia.  In  the  other 
case  two  unsuccessful  attempts  under  ether  had  been  made,  one  of  an 
hour  and  the  other  of  an  hour  and  a  half.  It  only  required  a  few  min- 
utes in  the  author's  clinic  in  each  instance  to  remove  the  foreign  bodies 
without  anesthesia,  general  or  local,  under  ocular  guidance  by  oral  bron- 
choscopv  in  the  regular  way.  Tracheotomy  had  been  done  for  the  pre- 
vious unsuccessful  fluoroscopic  bronchoscopies.  For  obvious  reasons, 
the  author  does  not  care  to  publish  further  details.  Sufficient  is  here 
given  to  emphasize  the  practical  point  that  the  author  wishes  to  make. 
Namely  that  fluoroscopic  bronchoscopy  is  so  deceptively  easy  from  a 
superficial  theoretical  point  of  view  that  it  has  been  used  unsuccessfully 
in  cases  easily  handled  in  the  regular  endoscopic  way.  The  author 
has  been  able  to  collect  12  cases  of  fluoroscopic  bronchoscopy  for  foreign 
bodies  of  which  the  following  is  an  analysis : 

Statistics  of   fluoroscopic  bronchoscopy    for   foreign   bodies  by  va- 
rious operators: 

Foreign  body  removed  in  8     (66.7  per  cent). 

Foreign  bodies  not  removed  4     (33.3  per  cent). 

Number  of  cases  fatal  within  a  week       5     (41.6  per  cent). 

Of  fatal  cases  foreign  body  removed  in    3     (60     percent). 

Of  fatal  cases  foreign  body  not  removed  2  (40  per  cent). 
From  the  foregoing  it  is  clear  that  fluoroscopic  bronchoscopy  be- 
cause of  its  high  mortality  and  its  low  percentage  of  successes,  has  noth- 
ing to  justify  its  use  in  any  bronchially  lodged  foreign  body  case  vuitil 
after  regular  Killian,  ocularly  guided,  endoscopic  bronchoscopy  has 
failed.  Personally  the  author  would  not  use  it  until  after  another  en- 
doscopist besides  himself  had  failed.  Its  use  is,  of  course,  only  possible 
in  case  of  bodies  very  dense  to  the  ray  and  such  as  can,  by  posture,  be 
seen  clear  of  the  heart  and  spinal  shadows.  Practically  all  of  the  cases 
reported  have  required  tracheotomy.  Fluoroscopic  bronchoscopy  is  an 
improvement  on  the  old  method  of  using  forceps  blindly  through  the 
tracheotomic  wound ;  but  it  is  a  step  backward  as  compared  to  Killian 
bronchoscopy,  and,  because  of  its  high  mortality  and  lack  of  success,  it 
is  justifiable  only  when  Killian  bronchoscopy  has  failed. 

Briinings  has  devised  a  lead-ended  probe  for  radiographic  localiza- 
tion. 


CHAPTER     XVI. 

Foreign  Bodies  in  the  Bronchi  for  Prolonged  Periods. 

Cases  of  foreign  bodies  of  prolonged  sojourn,  say  a  year  or  more, 
in  the  bronchi  require  special  consideration.  Just  what  length  of  so- 
journ is  to  be  regarded  as  "'long,"  is,  of  course,  difficult  to  say.  The 
secondar}'  changes  which  make  the  ditierence  requiring  special  consid- 
eration set  in  after  a  few  weeks,  in  some  cases  and  a  few  months  in 
others,  but  bronchiarctia,  bronchiectasis  and  abscess,  in  the  author's  ex- 
perience, have  been  encountered  only  after  a  period  of  a  year  or  more. 

Etiology.  The  causes  leading  to  the  prolonged  sojourn  of  a  for- 
eign body  may  be  classified  under  three  heads: 

1.  Ignorance   of   its   presence. 

2.  Inability  to  make  a  diagnosis  when  suspected. 

1  High  mortality  attending  efforts  at  removal  in  the  pre-bron- 
choscopic   days. 

The  cases  hereinafter  reported  as  well  as  common  experience  show 
that,  strange  as  it  may  seem,  practitioners  are  heedless  of,  and  even  scofif 
at.  the  patient's  suspicions  that  a  long  previously  aspirated  foreign  body 
is  the  cause  of  present  symptoms.  This  is  largely  due  to  failure  to  recog- 
nize and  to  teach  in  colleges  the  fact  that  there  is  a  prolonged  symptom- 
less quiescent  period  after  the  aspiration  of  a  foreign  body  into  the  lungs. 
When  a  patient  states  that  he  has  neither  felt  anything  nor  coughed  for 
months  after  the  suspected  accident,  theoretically  the  presence  of  a  for- 
eign body  in  a  lironchus  seems  impossible;  yet,  practically,  we  know  that 
is  just  the  usual  course  of  such  cases.  The  difficulty  of  diagnosis  prior 
to  the  days  of  radiography,  and  still  existing  in  cases  of  intruders  not 
dense  to  the  ray,  has  been  an  important  factor  in  the  etiology  of  the  cases 
we  now  see.  Another  imjiortant  factor  is  that  prior  to  the  days  of 
bronchosco])y  the  then  stale  of  intrathoracic  surgerj-  rendered  interven- 
tion inadvisable  until  after  abscess  formation.  For  surgical  safety,  as 
well  as  because  the  abscess  often  could  not  be  located  prior  to  the  de- 


298  FOREIGN  BODIES  IN  BRONCHI  FOR  PROLONGED  PERIODS. 

velopment  of  radiography,  waiting  for  invasion  of  the  pleura  was  usually 
advised. 

Pathologx.*  Doubtless  verv  minute  bodies  become  encysted  or 
invade  the  interlobular  connective  tissue,  as  in  anthracosis,  but  aspirated 
foreign  bodies  of  larger  size  apparently  rarely,  if  ever,  become  encysted, 
though,  as  in  one  of  the  author's  cases,  the  foreign  body  may  migrate 
and  become  somewhat  "pocketed."  It  is  evident  from  bronchoscopic  find- 
ings that  a  foreign  body  too  large  for  anthracosis,  by  gravity,  as  well  as 
by  aspiration,  reaches  the  smallest  bronchus  it  can  enter,  where  it  stops. 
Later  negative  pressure  draws  it  still  further  downward.  By  mechanical 
irritation  alone,  or,  more  likely,  from  this  combined  with  pyogenic  or- 
ganisms carried  down  with  the  foreign  body,  there  results  a  productive 
inflammation  which  first  completely  occludes  the  involved  bronchus  with 
swollen  mucosa  (plus  the  bulk  of  the  foreign  body  itself)  ending  in  ab- 
scess of  the  lung  below  the  foreign  body.  Later,  sloughing  or  ulcer- 
ation follows  in  the  tissues  surrounding  the  foreign  body,  permitting  the 
slow  escape  of  discharges,  which  because  of  the  lessened  expulsive  cough 
efifort  from  below  consequent  on  the  obstruction,  tend  to  accumulate, 
producing  the  condition  of  bronchiectasis  above  the  obstruction.  In 
time,  the  obstruction  owing  to  the  productive  inflammation  becomes  a 
cicatricial  stricture.  Below  the  stricture,  the  abscess  cavity  becomes,  in 
a  sense,  a  bronchiectatic  cavity,  also.  The  loss  of  the  cilia  and  even 
of  the  epithelium  itself  follows,  and  increases  the  stagnation  of  the  se- 
cretions. The  bronchial  wall  may  be  destroyed  by  ulceration  and  chon- 
drial  necrosis,  and  the  foreign  body  may  wander.  The  law  of  gravity 
would  lead  one  to  expect  to  find  the  foreign  body  at  the  bottom  of  the 
cavity  in  the  formation  of  which  it  has  been  the  chief  etiologic  factor. 
In  two  of  the  author's  cases  it  was  at  the  top.  close  under  the  stricture. 
The  following  seems  a  plausible  explanation :  The  abscess,  of  course, 
forms  below  the  obstruction,  but  by  the  time  the  substrictural  bron- 
chiectatic cavity  has  been  produced,  the  foreign  body  has  become  suf- 
ficiently fixed,  by  organization  of  a  part  of  the  surrounding  granulation 
tissue,  to  hold  the  body  in  its  place  at  the  top  of  the  cavity  which  it 
has  caused.  The  development  of  a  stricture  above  the  foreign  body  is 
plausibly  explained  by  the  ulceration  which  is  more  or  less  annular. 
Such  ulceration  in  any  channel  or  tube  in  the  body  always  results  in 
more  or  less  constriction  of  the  lumen  when  the  scar  tissue  contracts. 
That  it  does  not  occur  to  the  same  extent  immediatelv  below  the  foreign 
body  is  probably  due  to  the  conditions  which  cause  the  substrictural  bron- 
chiectasis.    The  reader  interested   in  the  etiolog)-   and  pathogenesis  of 

*Ab.stracted  fwith  revision  and  additions)  from  a  paper  read  by  the  autlior  at 
the  meeting  of  the  I.ar.vnsoloKical  Section  of  the  American  Medical  Association. 
June,  1912. 


FOKIvICN  BODIES  I.N    llNi  i.\  ClI  I    I'OK  I'Ri  i|,i  >.\GF.I)  PI'.KIOUS.  399 

bronchiectasis  is  referred  to  the  excellent  article  of  C.  P.  Howard  (Bib. 
214).  In  some  cases  communication  with  the  subjacent  bronchi  is 
permanently  closed  by  intiammatory  sequelae,  and  the  abscess  may  be- 
come walled  off  and  so  remain  for  years.  Sooner  or  later,  however,  if 
the  patient  survive,  the  abscess,  probably,  will  burst  into  the  same  bron- 
chus or  a  branch,  or  it  will  burst  into  the  pleura.  There  seems  to  be  a 
strong  tendency  for  foreign  bodies  to  work  toward  the  periphery  as 
shown  by  the  consecutive  radiographs  in  one  of  the  author's  unsuccess- 
ful cases.  This  seems  to  be  the  tendency  whether  the  abscess  is  closed 
off  from  broncliial  drainage  or  not,  but  the  history  of  nearly  all  cases 
seems  to  show  that  drainage  is  usually  interrupted  for  a  greater  or 
lesser  time,  so  that  all  cases  are  closed  abscesses  for  part  of  the  time. 
Atelectasis  of  the  occluded  lung  area  is  usual  with  foreign  bodies  that 
occlude  a  bronchus,  and,  if  prolonged,  eventual  functional  destruction 
by  the  secondary  processes  is  the  usual  result.  Emphysema  and  not 
atelectasis  may  in  rare  instances  follow  the  presence  of  a  foreign  body 
as  shown  by  Iglauer  (Bib.  22:!).  Cases  of  foreign  bodies,  such  as 
pins,  that  because  of  their  small  diameter  are  not  obstructive,  usually 
are  not  quickly  followed  Ijy  secondary  changes,  as  noted  by  James  ^\  . 
MacFadane  at  thoracotomy.  Eventually,  however,  secondary  inflam- 
matory sequelae  will  cause  occlusion  of  the  invaded  branch  bronchus  and 
all  the  sequelae  of  a  pent  up  infected  focus  may  be  looked  for.  Gan- 
grenous bronchitis  and  pneumonitis  have  been  recorded  as  following  the 
aspiration  of  a  foreign  body,  but  they  are  very  rare  sequelae. 

A  distinction  should  be  made  between  an  area  of  ''drowned  lung" 
(natural  ])assages  full  of  pus)  and  a  true  abscess  cavity. 

Prognosis.  If  unremoved  the  foreign  body  will  almost  certainly 
prove  fatal.  If  removed  most  cases  will  recover  without  further  local 
treatment.  A  few  will  re(|uire  bronchoscopic  attention  to  drain- 
age. All  cases  will  need  a  general  antituberculous  regime,  and  if  this  can 
be  followed  the  prognosis  is  good.  In  a  small  percentage  of  cases  exten- 
sive secondary  changes  as  in  one  of  the  author's  cases  (Edward  M.)  an 
infective  embolus  from  the  lung  or  endocardial  focus,  before  complete 
resolution  has  ensued,  may  lodge  in  a  vital  spot  and  end  fatally,  just  as 
sometimes  hajipens  without  lironchosco])ic  or  other  remo\al. 

Indications  for  bronchoscopy  for  foreign  body  of  prolonged  sojourn. 
r.ronclioscoi)y  for  removal  is  urgently  indicated  in  every  case  in  which 
there  is  any  expectoration.  In  cases  with  ,i  histon,'  of  intcnnitlcnt  ex- 
pectoration of  foul  pus.  it  is  better  to  do  the  bronchoscoijy  during  the 
discharging  i)erif)d,  rather  than  in  the  dry  interval,  so  that  following  the 
pus  to  its  source  will  lead  the  bnnKlioscopist  to  the  foreign  bodv.  Feeble- 
ness, even  ;ipproaching  a  moribund  condition,  is  no  contraindication,  as 


300  FOREIGN  BODIES  IN  BRONCHI  FOR  PROLONGED  PERIODS. 

shown  by  the  author's  case  (Mrs.  K.),  provided  no  anesthetic,  general 
or  local,  is  used.  In  cases  in  which  there  is  a  long  period  of  cessation  of 
discharge  even  though  the  patient  is  in  good  health,  an  exploratory  bron- 
choscopy is  indicated.  If  m  such  a  "dry"  case,  a  thick  barrier  is  found 
bronchoscopically  with  no  fistulous  opening,  and  the  radiograph  shows 
an  abscess  close  to  the  external  wall  of  the  chest,  external  operation  by 
the  general  surgeon  may  be  indicated.  Of  course,  it  is  not  known  how 
frequently  foreign  bodies  may  be  the  cause  of  bronchiectasis,  but  the 
similaritv  of  the  symptoms  in  bronchiectasis  and  in  foreign  bodies  in  the 
bronchi,  would  certainly  render  exploratory  bronchoscopy  advisable  even 
in  a  case  with  a  radiograph  negative  as  to  foreign  body.  The  same  may 
be  said  of  circumscribed  pulmonary  abscess,  especially  if  tuberculosis  can 
be  excluded,  though  it  is  not  impossible  that  a  tuberculous  process  may 
exist  primary  or  secondary  to  foreign  body  lodgment. 

In  all   cases  of  doubt  bronchoscopy   is  a   harmless  procedure   that 
should  be  done  anyway. 

Symptomatology  and  diagnosis.  After  the  aspiration  of  a  foreign 
body  into  the  trachea  and  bronchi,  there  is  a  longer  or  shorter  period  of 
perfect  health  in  which  the  patient  has  no  symptoms  whatever.  It  is 
often  difficult  to  convince  the  family,  and  even  the  family  medical  ad- 
visor, that  a  foreign  body  can  be  present  and  not  produce  any  cough, 
bloody  expectoration,  dyspnea,  rise  of  temperature,  or  any  other  s\mptom. 
Nevertheless,  nearly  all  small  foreign  bodies  that  reach  the  bronchi  do  not 
produce  any  such  s\mptoms  for  a  variable  period  of  weeks  or  sometimes 
months.  Then  begins  a  gradual  turn  to  failing  health,  the  exact  cause  of 
which  is  often  unsuspected.  There  may  be  slight  cough  with  scanty  ex- 
pectoration, slight  temperature  elevation,  some  malaise,  with  slight  loss 
of  weight,  and  altogether  a  picture  of  incipient  tuberculosis,  which,  in- 
deed, has  been,  undoubtedly,  the  diagnosis  in  many  cases.  The  close 
parallel  between  the  symptoms  noted  in  these  cases  and  in  pulmonary 
tuberculosis  even  to  the  clubbing  of  the  fingers  (see  case  of  Edward  M.) 
would  seem  to  render  it  advisable  to  Stispect  the  presence  of  a  foreign 
body  in  every  case  of  seeming  tuberculosis,  in  wdiich  no  bacilli  are  found 
in  a  purulent  sputum,  and  especially  if  the  symptoms  are  confined  to  the 
lower  lobe,  particularly  the  right  lower  lobe.  This  would  still  leave  out 
the  cases  of  foreign  body  in  which  a  tuberculous  infection  has  preceded, 
or,  more  often,  followed  the  aspiration  of  a  foreign  body.  Tw'o  of  the 
author's  cases  (Brooks  G.  and  Mary  X.)  Iiad  such  marked  signs  of 
pleurisy  that  they  had  been  previously  tapped  without  getting  fluid.  In- 
gals  reports  a  similar  case.  The  erroneous  diagnosis  of  pleural  disease  in 
these  and  other  cases  of  foreign  body  in  the  lungs  has  been  ably  pointed 
out  by  Boyce  (Bib    14). 


i-iiui;if..\  r,(iini;s  in  liKdNCiii  imr  I'koi.dngkd  periods.  301 

The  use  of  the  radiograph  as  a  routine  procedure  would  certainly 
seem  indicated  in  the  diagnosis  of  thoracic  disease.* 

'J'rcdtiitcnt.  I'us.  granulomata,  blood  and  stricture  are  the  obstacles 
to  be  overcome  in  dealing  with  foreign  bodies  of  long  duration.  As 
large  a  quantity  of  pus  as  possible  should  be  removed  by  posture  and  vol- 
untary cough  before  bronchoscopy.  As  a  rule  the  morning  is  the  worst 
time  to  operate  because  of  the  accumulation  over  night.  By  afternoon 
much  pus  can  have  been  expectorated.  Children  can  be  held  up  by  the 
ankles  during  coughing  jjaroxysms.  Adults  may  be  placed  on  the  sound 
side,  pillowless,  on  a  bed  elevated  high  at  the  foot.  Antibechics,  bad  at 
any  time,  should  be  esjiecially  forbidden  during  the  forty-eight  hours  pre- 
ceding bronchoscopy.  What  pus  remains  should  be  removed  at  the  first 
stage  of  bronchoscopv  by  the  author's  "sponge  pumping"  process  pre- 
viously herein  described.  For  this,  work  without  anesthetic  is  a  great 
help.  If  anesthesia  is  used,  as  the  author  did  in  some  of  the  adult  cases, 
the  cough  reflex  should  not  be  altogether  abolished.  It  is  very  essential 
in  the  preliminary  examination  to  use  the  sponges  very  gently  in  getting 
out  the  pus,  so  as  to  avoid,  if  possible,  traumatism  to  the  granulations, 
which  may  cause  quite  a  good  deal  of  bleeding  and  thus  obscure  the 
field.  'Jf  course,  after  the  first  survey  of  the  field,  it  is  often  necessary 
to  remove  the  granulations  with  forceps.  During  this,  the  sponging  can 
be  fairly  vigorous,  but  removal  of  the  granulations  should  not  be  begun 
until  after  the  preliminary  survey.  It  will  require,  in  some  instances,  as 
much  as  three-quarters  of  an  hour  to  get  the  field  entirely  clear  of  gran- 
ulation tissue,  pus  and  secretion,  and  to  get  the  blood  wiped  away  and 
the  bleeding  stopped.  This  is  usually  time  well  spent,  because  it 
enables  more  prompt  work  when  the  foreign  body  finally  comes  into 
view.  The  difficulties  of  contending  with  abundant  granulation  tissue, 
is  well  described  by  Ingals,  as  follows:  "The  moment  this  tissue  was 
disturbed,  bleeding  occurred  which  obscured  the  field  of  vision  and  caused 
great  delay  from  the  necessity  of  swabbing  away  the  blood.  This  is  one 
of  the  greatest  difficulties  when  granulomas  are  encountered  in  these 
cases,  and  one  which  occupies  at  least  nine-tenths  of  the  operators  time. 
When  bleeding  has  been  checked  and  tlic  field  of  vision  once  more 
cleared,  the  next  portion  of  granulation  tissue  that  is  removed  causes  a 
repetition  of  the  whole  procedure;  and  this  is  likely  to  occur  repeatedly 
before  the  foreign  bcjdy  can  be  seen."  This  statement  has  absolutely 
nothing  to  do  with   the    form  of  distal    inuniiiiation   which    lugals   uses. 

•.lust  a.i  tlu'.'ic  pagi'S  no  to  pres.s,  I  >r.  fleorge  i>.  Richards  made  a  diagnosis  of 
a  foieiKn  l)0(3.v  In  the  lung-  upon  aif  unexplained  U'ucocytosl.s,  cough,  negative 
.sputum  examination  and  jihysical  .><iKn»  of  bronchial  obstiuction.  Diagnosis 
vi-rifled  b.v  radioHT-aphir  tlndins:  and  bi-onchoscopic  removal  of  a  tack  of  the 
a.splration  of  which  the  patient  had  no  recollection. 


302  FOREIGN  BODIES  IN  BROXCHI  FOR  PROLONGED  PERIODS. 

There  is  no  form  of  illr.mination  which  wiU  permit  the  observer  to  see 
through  a  pool  of  blood. 

The  probability  of  location  of  the  foreign  body  at  the  top.  instead 
of  at  the  bottom  of  the  abscess  cavity  in  strictured  cases,  is  a  point  of 
greatest  importance,  as  without  the  advice  of  Dr.  Boyce  on  this  point, 
the  search  in  two  of  the  author's  subsequently  mentioned  cases  would 
have  been  prolonged,  and  might  have  been  futile ;  because  the  foreign 
body  was  not  in  either  instance  free  in  the  cavity.  On  the  contrary,  it 
was  fixed  and  bedded  in  granulation  and  fibrous  tissue,  external  to  the 
bronchial  wall,  through  which  it  had  eroded  its  way.  The  location  of  the 
intruder  outward  under  the  overhang  of  the  cicatricial  stricture  rendered 
the  finding  of  the  foreign  body  difficult,  if  not  impossible,  without  dila- 
tation of  the  superjacent  stricture.  Xo  useful  forceps  could  have  been 
inserted  through  the  strictures,  in  the  two  cases  referred  to ;  the  foreign 
body  could  not  have  been  found  and  certainly  could  not  have  been  with- 
drawn. If  withdrawal  were  possible,  trauma  would  have  been  extensive, 
and  probably  fatal.  The  dilatation  of  the  purely  cicatricial  tissue  of 
the  stricture  was  harmless.  Further,  and  very  important,  the  dilatation 
improved  the  drainage,  so  that  Xature  could  care  for  the  lesions  result- 
ing from  the  long  sojourn  of  the  intruder. 

The  method  of  dilatation  by  divulsion  used  in  these  cases  possesses 
the  following  advantages : 

1.  It  is  safe  because  it  is  under  the  guidance  of  the  eye  and  the 
trained  touch,  by  which  both  the  direction  and  the  extent  of  the  dila- 
tation are  accurately  limited  at  will. 

2.  It  does  not  require  tracheotomj'  in  any  case. 

3.  There  is  no  danger  of  pushing  the  foreign  body  downward  as 
is  possible  in  certain  cases,  if  anything  in  the  shape  of  a  bougie  were  to 
be  used.  Pushing  a  foreign  body  downward  not  onlv  makes  removal 
more  difficult  but  involves  serious  risk  of  rupturing  the  bronchus. 

Jr.  It  is,  obviously,  better  adapted  than  tent  dilatation  to  foreign 
body  cases,  and  is.  in  any  case,  much  safer  and  simpler. 

The  method  is  simple.  The  divulsor.  Fig.  4.'),  is  inserted,  under 
guidance  of  the  eye,  into  the  stricture  which  is  stretched  to  the  maxi- 
mum expansion  of  the  instrument.  Then  the  larger  divulsor,  Fig.  4(5,  is 
used  to  its  maximum.  This  will  jjermit  the  entrance  of  the  closed 
side  curved  forceps,  Fig.  20,  with  which  the  cavity  can  be  probed. 
When  the  intruder  is  felt  the  forceps  can  be  expanded  and  tlie  intruder 
grasped ;  and  if  it  does  not  come  readily  through  the  stricture  the  for- 
ceps can  be  rotated,  if  the  foreign  body  be  not  such  as  to  cause  danger- 
ous trauma.  A  tack  or  pin  wrongly  grasped  cannot  be  pulled  through 
a  firm  cicatricial  stricture.     It  is  necessary  to  release  the  hold  at  the  top 


FOKKK^X  HoniES  IN"   BRONCHI  FOR  rRUI.ONGED  PERIODS.  303 

(near  end  in  tlu-  recumbent  jiatient  )  of  the  cavity,  and  examine  the  po- 
sition and  sliape  of  the  foreign  body  and  get  a  fresh  hold  planned  ac- 
cording to  the  mechanical  problem  presented.  In  some  instances  the 
cavity  can  be  explored  by  gently  forcing  the  conical  ended  tube  (Fig. 
IS),  into  the  already  partially  dilated  stricture.  In  case  of  tacks  lodged 
point  upward  the  point  may  project  upward  through  the  stricture.  If 
traction  demonstrates  a  firm  strictural  obstruction,  the  dilator,  Fig.  40, 
which  is  hollow  may  be  pushed  down  outside  the  stem  of  the  tack,  and 
the  stricture  dilated  without  risk  of  pushing  the  tack  downward.  The 
conical  ended  tube  may  be  used,  the  point  of  tack  seized  and  then  the 
stricture  dilated  by  forcing  the  bronchoscope,  forceps  and  tack  all  down 
together,  before  withdrawal. 

In  one  case  of  prolonged  sojourn  the  stricture  was  so  firm  and 
unyielding  that  prolonged  intubation  with  metallic  tubes  was  re<|uired. 
A  tracheotomy  was  done  and  the  tube  inserted,  removed  at  intervals  of 
a  few  days  and  reinserted  under  local  anesthesia.  For  further  details 
see  Hriinings'  book  (  Hib.  (52)  or  Mr.  Howarth's  excellent  translation 
(Bib.  208). 

In  one  of  the  author's  cases  (Mrs.  K.)  recited  below,  instead  of  a 
stricture  there  was  a  mass  of  cicatricial  tissue  with  small  fistulae  tilled 
with  buds  of  granulation  tissue.  This  ])lug  of  cicatricial  tissue,  as  shown 
by  the  radiograph,  was  about  two  centimeters  in  depth  and  beyond  lay 
the  foreign  body.  Fortunately  the  accurate  advice  of  the  radiographer, 
Dr.  George  C.  Johnston,  enabled  the  author  to  excise  this  intervening 
tissue  and  thus  to  reach  and  extract  the  foreign  body.  Without  the 
guidance  of  an  extraordinarily  good  radiogra])h  showing  the  bronchus 
for  a  sufficient  distance  above  the  tissue  barrier,  thus  giving  a  line  of 
direction,  such  removal  is  exceedingly  hazardous  as  to  both  life  and 
successful  foreign  body  removal.  Fluoroscopic  guidance  is  unsafe  un- 
less the  fluoroscopy  is  done  by  two  independent  fluoroscopists,  one  for 
the  vertical  and  one  for  the  horizontal  screen,  while  the  bronchoscopist 
follows  the  dictates  of  the  endoscopic  image  and  of  this  general  sense 
of  direction.  Even  under  these  circumstances  the  procedure  is  hazard- 
ous. 

Particular  care  must  be  taken  not  to  lose  the  foreign  bt)dy  from 
the  gras])  of  the  forceps.  The  risk  involved  is  especially  great  if  the 
intruder  be  large  enough  to  be  ol)structivc  because  if  it  should  enter 
and  occlude  the  sound  bronchus,  the  diseased  side  may  be  so  atrophied 
as  to  be  useless  and  the  jiatient  may  die  before  the  intruder  can  be 
again  grasped  and  removed.     This  accident  happened  to  Hinsl)erg. 

/Iftcr-care.  Local  treatment  has  not  been  necessary  in  the  author's 
cases,  of  2,  7,  10  and  2U  years  resjjectively.     If,  however,  there  seems 


304  FOREIGN  BODIES  IN  BRONCHI  FOR  PROLONGED  PERIODS. 

to  be  a  serious  degree  of  bronchiectatic  pus  retention,  or  the  patient 
fails  to  improve,  after  a  few  months,  a  radiograph  should  be  made  and 
compared  with  one  made  immediately  after  the  foreign  body  removal. 
All  of  the  author's  cases  were  thus  examined  and  all  were  making  such 
excellent  progress  that  nothing  further  was  done.  In  case,  however, 
of  serious  lack  of  drainage  repeated  dilatations  and  intubations  of  the 
strictural  obstruction  to  drainage  is  indicated.  This  was  done  by  Kil- 
lian  and  Briinings  in  the  case  referred  to  and  will  be  necessary  in  a  cer- 
tain proportion  of  cases. 

General  treatment  after  the  removal  of  a  foreign  body  of  prolonged 
sojourn  is  quite  essential.  Milk,  eggs,  rest  in  bed  oiU  doors  are  indi- 
cated.    In  fact  the  entire  anti-tuberculous  regime  is  highly  efficient. 

author's  BROXCIIOSCOPIC  C.XSES  OF  FOREIGN  BODY  OF  PROLONGED  SOJOURN. 

Brass  fastener  reinozrd  by  oral  broiielwscof'y  from  right  broncluis 
after  sez'eii  years'  sojourn.  Alary  X.,  aged  2?).  was  seen  in  consultation 
with  Drs.  J.  Sotis  Cohen,  D.  Braden  Kyle  and  Tello  d" Apery.  The  patient 
gave  a  history  of  continual  cough  and  foul,  yellowish  expectoration  ff^- 
about  a  year  and  a  half,  during  which  time  she  had  an  irregular  tempera- 
ture elevation  and  had  lost  weight.  For  seven  years  she  had  been  sub- 
ject to  severe  cough  witii  expectoration  during  the  winter,  these  symp- 
toms disappearing  in  summer.  The  diagnosis  of  pulmonary  tuberculosis 
had  been  made  by  a  number  of  physicians.  The  foregoing  is  in  brief  the 
history  she  gave  on  admission  to  Jefferson  College  Hospital. 

Radiographic  examination.  Dr.  Solis  Cohen  in  consultation  with 
Dr.  d'Apery  found  both  apices  free  from  disease.  The  only  abnormal 
physical  signs  were  slight  impairment  of  resonance  at  the  right  base,  with 
dim.inished  voice  and  breath  sounds.  As  these,  in  his  opinion,  did  not 
sufficiently  account  for  the  symptoms,  he  referred  the  case  to  Dr,  Willis 
F.  Manges  for  radiographic  study.  Dr.  Manges  in  a  beautiful  stereo- 
scopic radiograph  (Fig.  184)  showed  a  stricture  of  the  right  bronchus, 
with  a  metallic  body  resembling  an  upholsterer's  tack,  point  upward, 
below  the  stricture  and  behind  the  bronchus.  The  patient  remembered 
having  "swallowed"  a  price  tag  fastener  seven  years  before,  but  as  she 
was  told  that  it  would  pass  harmlessly,  she  had  forgotten  the  occurrence. 
She  had  had  no  symptoms  whatever  until  the  winter  following  the  acci- 
dent.    Symptoms  recurred  each  winter. 

Bronchoscopy.  At  Jeiiferson  College  Hospital  before  the  members 
of  the  American  Laryngological  Association,  the  author  passed  a  broncho- 
scope through  the  mouth.  The  trachea  was  full  of  foul,  purulent  secre- 
tion  which  was   removed  by  "sponge  pumping,"   the  patient  being  kept 


FOREIGN  nODII-S   IN   liKONCHI  FOR  PROLONGliD  PERIODS.  305 

only  partially  under  cIIkt  Id  i^ain  Ihc  aid  of  the  cough  retlex/''  The  last 
of  the  secretion  removed  from  the  right  bronchus  was  mixed  with  blood. 
The  right  main  bronchus,  just  below  the  orifice  of  the  middle  lobe  bron- 
chus, was  occluded  by  a  tirm  stricture,  the  lumen  of  which  was  a  mere 
slit,  extending  about  ■'<  mm.  laterally,  and  with  mi  apiirecialile  antero- 
posterior diameter,  the  anterior  and  posterior  edges  being  in  contact.  At 
each  coughing  efl'ort,  bloody  secretion  was  forced  through  the  slit.  The 
stricture  was  dilated  with  the  author's  divulsors,  in  the  direction  of  the 
narrowest  diameter.  Then  the  source  of  the  bleeding  .md  the  blood- 
stained secretion  was  found  to  be  a  mass  of  granulations  located  below 
the  stricture  and  j^osteriorly.  Dclow  this  was  a  large  cavity  from  which 
a  <|uantity  of  very  thicl<  pus  was  removed.  This  pus  was  not  foul  like 
the  tracheal  pus.  (  Possibl_\-  the  author's  olfactory  sense  was  by  this  time 
obtuiided.)  On  exploration,  with  bronchoscopic  lateral  displacement,  the 
mass  of  granulation  tissue  at  the  top  of  the  cavity  posteriorly  was  found 
to  protrude  from  an  accessory  ca\ity,  extending  posteriorly  and  median- 
ward,  outside  of  the  bronchus.  (  )n  removal  of  the  granulation  tissue, 
the  foreign  body  was  fnuiul  and  reni()\eil.  It  ])roved  to  be  a  jirice  tag 
fastener  (Fig.  185). 

Patlwlugist's  iwf'ort.  The  granulatidn  tissue  removed  was  examined 
by  Dr.  Ernest  W  \\  illell>,  who  reported  as  follows:  Specimen  consisted 
of  several  very  small  pieces  of  tissue.  Microscopic  examination  shows  a 
covering  of  stratified  s(|uamous  epithelium  which  has  normal  appearance 
but  is  thickened  considerably  at  some  points.  T'.eneatli  the  epillieliuni 
there  was  a  mass  of  connective  tissue  showing  manv  mast-cells,  fibro- 
blasts, new  blood-vessels  and  some  older,  more  fibrous  areas.  There  is 
also  considerable  niund-cell  inl'illration.  The  jirocess  appears  t(i  be  a 
chronic  infiamm.-ilory  (iiie.  the  exact  n;ilnre  (if  which  is  not  exidenl  fnini 
microscopic  examination." 

Subsequent  history.  The  p:ilient  in:ide  an  entire  and  complete  re- 
covery, and  one  year  afterward,  Dr.  d'.\]iery  reported  that  she  was  work- 
ing at  her  occujiation  in  the  stocking  factory,  in  possession  of  perfect 
health,  the  cough  and  expectoration  having  beer,  totally  absent  for  the 
past  winter,  the  first  out  of  seven  winters.  The  patient  was  exhibited 
the  following  year  at  tiie  meeting  of  the  American  Medical  .Association 
and  now,  three  years  later,  is  still  in  perfect  health. 

Lead-alloy  collar  button  in  riglit  bronchus  ten  years.  Renioivl  by 
oral  bronchosecf'y.  Brooks  G.,  aged  eighteen  years,  small,  frail  and 
undevelojied  for  his  age,  ga\e  a  history  of  ])neumonia  eight  years  before 
(.1003),  followed  by  pleurisy  and  empyema,  which  one  year  later  (  l!Hi|  i 

•This  and  the  two  fuHuwiiic  cH.sr.^  oocurrpd  a  luiriilKr  of  yi-avs  tiKO.  In  latfi- 
ca.>!e.x  the  author  has  found  it  advantnKPous  to  woiU  with  local  anesthesia  in 
adults,  witliout  any  anesthesia  in  cliildren. 


30(1 


FOREIGN  BODIES  IN   BRONCHI  FOR  PROLONGED  PERIODS. 


was  tapped  and  drained.  Only  a  very  small  amount  of  pus  was  obtained 
and  drainage  during  three  months  was  very  unsatisfactory.  Temporary 
improvements  were  followed  by  relapses.  Chills  were  attributed  to  a 
supposed  malarial  infection  while  living  in  \'irginia.  An  eminent  in- 
ternist diagnosticated  pulmonary  tuberculosis,  since  which  time  treatment 
had  been  chieHv  climatic,  Ijv  residence  in  Arizona.     The  bov  never  re- 


Fic.  184. — Radiograph  by  Dr.  Willis  F.  Manges,  (Philadelphia)  showing  price- 
tag  fastener  which  had  been  seven  years  in  the  right  bronchus  of  a  girl  of  2,3  years. 
(Mary  N.).  Fastener  removed  by  oral  bronchoscopy  after  bronchoscopic  dilatation 
of  the  bronchia!  stricture  (Anther's  case). 


Fig.  185. — Price-tag  fastener  lodged  for  seven  years  in  the  lung  of  a  girl  aged 
23  years.  Removed  bronchoscopically  through  the  mouth  after  dilatation  of  the 
overlying  bronchial  stricture.  Only  one  branch  wire  shows  in  the  radiograph, 
because  the  two  were  in  line  (Author's  case). 


gained  his  health  sufihcientlv  to  dispense  with  a  nurse.  He  was  frail 
and  suffered  continually  from  cough,  usually  with  [)urulent  sputum,  fre- 
(|ucntly  pink-stained,  and  occasionally  of  foul  odor.  He  had  low,  irreg- 
ular temperature  elevation  very  suggestive  of  tuberculosis,  but  sputum 
examination  was  always  negative.  Dr.  J.  C.  Roper,  of  the  New  York 
Hospital,  after  careful  sputum  exannnations,  found  no  tubercle  bacilli 
and  no  elastic  tissue. 


I'OKlvK'.N   ]'.()l)llis  I.N   liKONCIU   FUK  I'KULONGEU  PICKIODS. 


:i07 


Rcfort  of  physical  e.viiniiuiliun  (Dr.  James  T.  Edijerion  and  Dr. 
John  W.  Boycc).  Patient  is  frail,  underweight,  pigcon-hreasted,  and  has 
marked  dextrocardia:  a;>iees  free  from  (h'sease.  l^hysical  sign-;  are  con- 
lined  to  base  of  right  hmg.  Low  down  posteriorly,  and  extending  to 
edges  of  lung,  both  breath  and  \fjice  sounds  were  increased  with  a  sug- 
gestion of  amphoric  breathing  and  whispered  pectoriloquy.  Xo  change 
in  percussion  note.  We  are  unable  tr>  demonstrate  either  tympany, 
cracked-pot  note  or  W'intrich's  change  of  tone  when  mouth  is  open. 


Fic;.  iSS. — R;uli<)j.'r;iiil)  In  I  )r.  l.iui-  (,i(.^ury  CUlc  (  .W'w  York)  sliovving 
lead  collar  Imttdii  (iniiui--  lu-;iil )  in  rii^lit  lung  of  a  boy  of  eighteen  years.  Re- 
moved lironclioscopioally  tlir()ii,i;li  tin-  nioutli,  after  diviilsinn  of  tile  iivcrlyiiiK 
stricture      (Author's  case). 


Such  was  the  history  and  the  condition  of  the  patient  when  taken 
to  Dr.  James  1.  Kdgerton.  of  New  York  City.  Unlike  his  predecessors. 
Dr.  Edgerton  did  not  conclude  that  all  the  physical  signs  were  attribut- 
able to  the  secondary  changes,  following  the  suppo.sed  empyema  of  eight 
years  before,  and  sought  the  aid  of  Dr.  Lewis  Gregory  Cole,  of  Xew 
York  City,  who  located  with  wonderful  accuracy  by  radiographic  tri- 
angulation.  a  portion  of  a  lead  collar  button,  midvyay  between  the  angle 
of  the  scapula  and  the  si)ine,  ii.  I  cm.  from  the  posterior  \yall  of  the 
chest.  The  collar  button  consisted  onl\-  of  a  base  and  post,  willuuit  .i 
top,  giying  the  a|i]:ear;incc  of  a   ri\et   as   seen   in   the   radiogra]ili    i  big. 


308  FOREIGN  BODIES  IN  liRONCHI  FOR  PROLONGED  PERIODS. 

isii).  The  parents  remeinljered  tliat  the  child  had  "choked  ten  years 
(symptoms  eight  years)  i)reviously  on  the  collar  button  ;  and  thev  had  re- 
iterated to  numerous  medical  attendants  their  suspicion  that  the  collar 
button  might  be  the  cause-of  all  the  symptoms,  and  in  recent  years  they 
had  even  requested  that  a  radiograph  be  taken."  I'.ut  the  scoffing  at  lay 
opinions  had  silenced  them.  \)v.  Edgerton  brought  the  boy  to  the  author. 
Bronchoscopy.  On  passing  the  bronchoscope  through  the  larynx, 
a  large  quantity  of  very  foul,  blood-stained  pus  was  continually  being 
coughed  up  from  below.  This  coughing  could,  of  course,  have  been 
stopped  by  deep  general  anesthesia,  but  the  cough  reflex  was  preserved 
under  slight  ether  anesthesia,  as  an  invaluable  aid  in  ridding  the  lower 
air  passages  of  the  foul  secretion,  which  obscured  everything.  After 
the  fluid  was  removed  from  the  trachea  by  "sponge  pumping,"  it  w.is 
easy  to  see  that  the  pus  was  coming  from  the  right  bronchus.  This  bron- 
chus was  pumped  out  and  then  it  could  be  seen  that  almost  all  the  right 
bronchus  was  a  bronchiectatic  cavity  with  a  cicatricial  bottom,  at  the 
right   edge   of   which    was   a    small   strictural   o|iening,    about   "^    mm.    in 


4t^ 


Fu;.  187. — Portion  of  lead  collar  Imtton  (kind  used  liv  laundries)  removed  by 
oral  bronchoscopy,  from  the  lung  of  a  hoy  (  Urooks.  G.)  aged  eighteen  year.s 
(Autlior's   case). 

diameter.  A  cicatricial  web  occluded  about  two-thirds  of  the  bronchial 
lumen  just  above  the  stricture  and  this  web  at  its  right  end  cur\e(l  down- 
ward forming  part  of  the  edge  of  the  stricture.  The  apertures  of  the 
upper  and  middle  lobe  bronchi  seemed  more  than  usually  oval  in  out- 
line, though  of  this  it  was  difficult  to  be  certain,  and  the  time  could  not 
be  spared  for  careful  examination,  since  it  was  practicall\-  certain  that 
the  collar  button  was  below  the  stricture,  which  therefore  must  be 
dilated.  The  di\ulsor  (Fig.  1"i  1  was  passed  and  readily  entered  the 
lumen  of  the  stricture.  The  divulsion  to  the  full  extent  of  the  instru- 
ment (1  cm.)  did  not  require  great  force.  After  the  withdrawal  of  the 
small  dilator,  the  large  dilator  (  Fig.  4ii )  was  introduced  and  expanded 
and  allowed  to  remain  //;  .v(7(/  for  a  few  minutes.  Next,  the  cavity  below 
the  stricture  was  wii)ed  out  with  small  bronchoscopic  swabs.  Basing 
his  judgment  on  the  fact  that  the  i)hysical  signs  as  above  given  were  be- 
low the  point  at  which  Dr.  Cole  located  the  foreign  body.  Dr.  lioyce  ad- 
vised the  author  that  the  collar  button  would  be  found  at  the  top  and 
not  the  bottom  of  the  aliscess  cavity.  Acting  on  this  advice,  a  small 
patch  of  granulation  tissue  was  found  immediately  uniler  the  overhang- 


VOKKIGN  I'.ODIKS  IN   liKOXClll  l-i  iK  I'KoLnNGKU  1'KKIkDS.  309 

]iig  left  edge  of  the  dilated  strictural  openings.  During  exploration  of 
this  granulation  tissue  with  the  jaws  of  the  foreeps  (Fig.  2!))  the  collar 
button  was  felt  and  removed.  -A.t  the  first  attempt,  the  tip  of  the  post 
of  the  button  came  away,  permitting  the  removal  of  the  balance  of  the 
button  (Fig.  ^^7)  edgewise.  The  boy  returned  to  his  home  a  few  days 
later,  and  four  months  afterwards,  entered  college  in  fairly  good  health. 
One  year  after  the  operation  he  was  reported  by  Dr.  H.  A\'.  Fenner,  of 
Tucson,  .Arizona,  to  be  free  from  cough  and  expectoration  and  other- 
wise healthy  and  normal  in  every  way.  Two  years  later  he  won  the 
tennis  championship  of  Colorado  after  a  long  and  arduous  training  and 
tournament.  Xow.  three  years  after  the  removal,  he  is  in  good  health 
and  averages  uj)  to  normal  development  for  his  age  except  in  height. 
Radiographic  study  by  Dr.  Cole  at  various  stages  of  convalescence  gave 
accurate  graphic  data  on  local  progress,  and  the  skillful  care  of  Drs. 
Edgerton  and  Fenner  contributed  largely  to  recovery. 

Brass-headed  tack  in  rhjlit  bronchus  two  years.     Rcmoird  h\  oral 
bronchoscopy. 


T 


Fig.     i88. — Urass-headcd  tack  that  n-niaiiu'd  for  two  years  in  tlic  liroiiclius  of 
a  woman  of  S-  years.    Removed  by  oral  l)ronchoscopy  (Author's  case). 

.Mrs.  J.,  aged  ')2  years,  referred  by  Dr.  j,  J.  Richardson.  Two  years 
previously  patient  had  choked  on  a  tack.  For  a  time  there  were  no  symp- 
toms, then  chronic  bronchitis  supervened,  followed  ever  since  by  irreg- 
ular fever  and  chilliness.  Occasional  expectoration  of  blood.  Repeated 
radiography  failed  to  reveal  the  tack,  until  a  week  before  admission, 
when  the  radiograph  (Fig.  l*o)  was  made.  Dr.  .\.  H.  Clark  reported: 
"I'reathing  diminished  throughout  right  chest,  marked  at  base  in  front, 
almost  absent  at  base  in  back.  Marked  auscultatory  signs  of  bronchitis 
on  right,  moderate  on  left."  .\t  the  T'resbyterian  Hospital  the  author 
at  oral  bronchoscopy  luider  ether  anesthesia  found  the  right  inferior  lobe 
bronchus  below  the  orifice  of  the  middle  lobe  bronchus  occluded  with  a 
fungating  bleeding  mass  of  granulation  tissue.  Quite  free  bleeding  fol- 
lowed excision  of  this.  After  al)out  seventy  minutes  of  work  all  of  the 
granulation  tissue  was  removed  and  a  dr\  Ik-id  was  obtaineil.  Careful 
search  over  this  field  revealed  on  the  |)osterior  wall  a  small  spot  where  a 
granulation  bud  had  been  nipjied  olT  at  the  orifice  of  a  dorsal  branch 
bronchus.  In  the  center  of  the  red  s]jot  was  a  black  spol  which  i)roved 
to   l;(.'   ilu'   point    ol    the    tack.      The   side-curxed    forcejjs   were    insiiuiated 


no 


FOREIGN  BODIES  IN  BRONCHI  FOR  PROUINGED  PERIODS. 


into  the  bronchial  orifice  and  the  intruder  withdrawn  by  a  firm  grip  of 
the  point  of  the  tack  (Fig.  188).  There  was  expectoration  of  blood  for 
a  week.  The  temperature  continued  to  rise  occasionally  but  in  about  a 
month  came  permanently  to  normal,  the  cough  and  expectoration  ceased 
in  about  three  months  and  now,  after  almost  two  years,  the  patient 
is  reported  by  Dr.  Richardson  to  be  in  perfect  health. 


Fig,  l8y. — Radioyraijh  uf  Mrs.  Is..,  showing  left  pyopucumuthurax  wliich  was 
due  to  the  bursting  into  the  pleura  of  a  foreign  body  abscess  of  the  lung  in  a 
woman  of  48  years.  Collar  button  was  in  the  lung  b\it  did  not  show  through  pus 
shadow      (Author's  case). 


Glass  collar  button  in  left  bronchus  for  tzvcnty-six  years.  Removed 
by  oral  bronchoscopy  -vithout  anesthesia,  general  or  local.  Mrs.  K., 
aged  48  years,  was  admitted  to  the  Presbyterian  Hospital  with  a  history 
of  having  "swallowed"  a  pearl  collar  button  twenty-six  years  previously. 
There  was  some  cough  and  bloody  expectoration  at  the  time  of  the  acci- 
dent and  for  about  a  year  subsequently.    This  was  before  the  discoveries 


FOKKICX   r.oDIKS  I.N    ItKdXCllI   l-UK  i'UOUIXGED  PKRIODS. 


HU 


of  bronchoscopy  and  roentgenoscopy.  Xo  further  puhnonary  symptoms 
were  noted  for  twenty-four  years.  During  the  twenty-fifth  year  there  was 
an  attack  of  "jjueumonia"  in  treating  which  the  attending  physician  (a 
\ery  competent  man  i  ridiculed  the  patient's  idea  that  the  button  could 
still  be  in  the  lungs.  In  the  early  part  of  the  twenty-sixth  year,  under 
the  care  of  a  third   plusician.  a  second  attack  of  pneumonia  occurred. 


Fic.  Kjo. —  Kadiij.L;r.i|ili  ol  M  i  >.  K.,  aiur  istcrnal  drainage  of  llic  abscess  by 
Ur.  J.  Hartley  Anderson.  Foreign  body  (collar  l)Utton)  present  did  not  show. 
The  dark  line  I'rom  the  first  rib  downward  and  outward  toward  the  drainage  tube 
is  the  thickened  visceral  pleura  seen  on  edge.  The  hing  is  collapsed  as  far  as  the 
pleural   adhesions   will   permit. 


followed  1)\  jiain  in  the  left  >idc.  bloody,  foul  expectoration,  lever  and 
emaciation.  Again  the  patient's  story  of  the  collar  button  was  ridiculed. 
Extremely  feeble  and  emaciated,  she  fell  into  the  hands  of  Drs.  Thomas 
I..  Ray  and  S.  H.  I'ierce  who,  on  the  ])h_\sical  signs,  made  a  diagnosis  of 
lung  abscess  and  i)yopneuniotliorax.  Suspecting  foreign  body  origin, 
they  referred  the  case  to  the  author. 


312 


FOREIGN  BODIES  IN  BRONCHI  FOR  PROLONGED  PERIDDS 


On  admission  to  the  l^rcsbyterian  Hospital,  the  woman's  tempera- 
ture was  102°,  pulse  1-10,  respirations  4U.  Sputum  was  profuse,  thick, 
foul  and  of  dark  gray  color.  A  radiograph  (Fig.  ISii)  by  Drs.  Johnston 
and  Grier  showed  a  dense  shadow  over  the  left  lung,  which  they  believed 
to  be  pus.  Dr.  John  W.  Boyce  corroborated  Dr.  Pierce's  findings  and 
urged  immediate  drainage  of  the  pleura  h\  rib  resection  and  a  wide  open- 


FiG.  191. — Quartering  lateral  radiograph  by  Dr.  Gcurgc  C.  Johnston  showing 
collar  bntton  in  tl.e  lung  between  the  heart  and  the  spine.  (Same  patient  as  Fig. 
190). 


ing.  This  was  done  by  Dr.  J.  Hartle\'  Anderson,  evacuating  over  a  quart 
of  putrid  pus,  Drs.  Johnston  and  Grier  then  made  another  antero-jios- 
terior  radiograph  (Fig.  IDO)  which  showed  that  the  ])us  was  well  drained, 
but  did  not  show  a  foreign  body.  In  further  search  they  made  a  diagonal 
radiograi)h  (Fig.  1!)1  )  which  showed  a  collar  button  between  the  heart 
and  the  spine,  in  direct  line  with  the  stem  bronchus  of  the  left  side.  Dr. 
Johnston  stated  that  there  was  tissue  overlying  the  foreign  body  and  that 


FOKHIGN  BODIKS  IN   BRONCHI  FOR  PROLONGICD  PERIODS.  313 

in  order  to  reach  the  foreign  body  it  would  be  necessary  to  remove  this 
tissue  in  a  direct  Hue  witli  the  axis  of  the  stem  bronchus.  W'itli  the 
assistance  of  Drs.  Patterson,  McCready  and  AIcKee,  without  anesthesia, 
general  or  local.  I  passed  a  bronchoscope  through  the  mouth  and  found 
the  inferior  lobe  bronchus  occluded  just  below  the  orifice  of  the  upper 
lobe  bronchus  by  a  cicatricial  mass  containing  three  apertures  through 
which  reddish  granulations,  that  bled  when  wiped,  w-ere  protruding.  Clear- 
ly, dilatation,  as  practiced  in  previous  cases,  was  useless  and,  with  the 
accurate  localization  and  advice  of  Dr.  Johnston  as  a  guide,  the  author 
excised  tissue  endoscopically  with  biting  forceps  until  a  rather  large  cav- 
ity full  of  granulations  was  reached.  Excising  the  granulations  and  wip- 
ing away  blood,  foul  pus  and  secretions,  the  collar  button  (Fig.  192) 
came  into  view  bedded  in  granulation  tissue,  from  which  it  was  readily 
removed  through  the  mouth  along  with  the  bronchoscope  and  forceps. 
The  foul  odor  disappeared  in  about  four  weeks,  cough  and  expectoration 
lessened,  and  both  ha\e  now  disa[)peared.    The  hmg  has  completely  filled 


■<<jedj^P 


Fic.  ig2. — Glass  collar  button  rcmoxed  from  the  lung  of  Mrs.  K.  by  oral 
bronchoscopy  without  any  anesthesia,  general  or  local.  It  had  been  in  the  lung 
for  twenty-six  years. 

with  air  as  shown  radiographically.  The  external  pleural  fistula  per- 
sisted for  a  number  of  months,  but  healed  completely  and  now,  one  and 
one-half  years  later,  Dr.  Pierce  reports  the  patient  to  be  in  perfect  health 
and  weighing  IT.")  pounds. 

The  ]Kjints  of  special  interest  are: — 

1.  The  extremely  long  sojourn  of  the  foreign  body  in  the  lung;  the 
longest,  to  the  author's  knowledge,  yet  recorded. 

2.  The  freedom  from  symptoms  after  the  first  year,  for  so  long  a 
]ieriod,  twenty-four  years.     This  is  exceptional. 

;{.  The  bursting  of  a  foreign  body  abscess  into  the  pleura,  while 
doubtless  not  of  tiie  greatest  rarity  of  occurrence,  has  been  recorded  in 
only  a  few  instances. 

I.  The  foreign  iiody  did  not  fdlldw  the  discharging  aiiscess  into 
the  pleura!  ca\  ity. 

•">.  The  necessity  of  the  most  exjiert  ray  work.  It  was  only  the 
t|uartering  lateral  radiograjih  that  could  show  this  foreign  body,  and  all 
ordinary  work  would  iia\e  been  negative.  Good  lateral  radiographs  are 
exceedingly  dilfK-idt  t(i  make  nf  adult  subjects. 


314  FORIUGN   BODIES  IN  BRONCHI   FOR  PROLONGED  PKRIODS. 

(5.  The  necessity  in  such  cases  of  draining  pus  collections  in  order 
to  get  a  radiograph  of  a  foreign  body,  which  would  not  show  through  the 
purulent  shadow. 

7.  The  feasibility  of  endoscopically  removing  a  tissue  barrier  in 
order  to  reach  an  ab.scess  cavity  in  the  lung,  when  guided  by  both  an 
accurate  radiographic  localization  and  ocular  evidence  through  the  tube 
that  the  tissue  to  be  removed  is  pathologic. 

8.  The  advantage  of  working  without  an  anesthetic.  This  patient 
was  in  extremis  and  an  anesthetic  was  not  to  be  thought  of.  Moreover, 
the  peroral  bronchoscopy  was  no  more  painful  than  the  filling  of  a  sensi- 
tive tooth  cavity,  for  which  no  one  re(|uires  an  anesthetic.  The  air  pas- 
sages were   full  of  pus  mixed   with   blood   from  the  granulations.     The 


Fig.  193. — Enlarged  view  of  fingers  from  a  pliotograpli  i>i  liands  of  Edward 
M.,  showing  "clubbing"  of  the  linger  ends.  (Author's  case).  Photographed  by 
Dr.  H.  H.  Fischer. 

coughing  of  the  unanesthetized  patient  greatly  assisted  in  remo\ing  this 
by  the  ''sponge  pumping"  method. 

Nail  in  left  bronclnis  four  years.  Remoi'cd  by  oral  hronclioseopy 
'ivithotit  anesthesia,  (je)icral  or  local.  Edward  AI.,  aged  ten  years,  re- 
ferred by  Dr.  Robert  L,.  Morehead,  of  New  York  City.  Four  years 
previously  the  child,  then  six  years  old,  aspirated  a  nail,  followed  by 
paroxysms  of  coughing  and  gradually  failing  health.  Sputum  examina- 
tion negative  as  to  tubercle  bacilli.  Mixed  pus  cocci  and  saprophytes 
were  present.  Dr.  H.  T.  Price  reported  the  results  of  his  physical  e.x- 
amination  as  follows : 

Child  fairly  well  developed,  rather  languid,  color  good,  head  large, 
fingers  markedly  clubbed  (Fig.  1!)3),  toes  not  so  large,  slight  cough  at 
intervals  of  half   to  two  minutes.     Breath  very  offensive   after  cough- 


FORKICN  liODIK.S  I\   r,R(t.\CUI   FOR  PROLONGED  PKRIUDS. 


■M-) 


ing,  especially  if  a  paro.\_\sni  occurs.  Pigeon  breast,  rather  emaciated 
chest,  indrawn  on  left  side  (Fig.  194).  Apex  beat  tumultuous  in  sixth 
interspace  and  about  one  inch  to  left  of  nipple  line.  Heart  much  en- 
larged to  left  barely  comjiensating  with  a  mitral  regurgitaliun  trans- 
mitted to  left  and  all  over  left  side  and  back.  Jugular  j)ulsati(jn.  Child 
camiot  lie  with  comfort  on  account  of  posture  causing  coughing  sf)ells, 


Fig.  194. — I'liotciHrapli  "f  Edward  M.,  aged  ten  years,  who  for  four  years 
had  a  nail  in  a  dorsal  brancli  of  the  posterior  lobe  bronchus.  Note  emaciation, 
"pigeon  breast,"  indrawn  on  left  side,  clubbed  fin^jers.  (Author's  case.  Photo- 
graphed by  Dr.  H.  H.  Fischer.) 


nor  can  he  lean  forward  without  distress.  Right  lung  negative  as  to 
dullness,  ncjrmal  breathing,  but  few  rales  on  deep  respiration.  Left 
chest  dull  all  o\er.  \'ery  little  air  entering  upper  lobes.  A  few  rales 
on  di'cp  inspiration.  Lower  lobe,  breathing  of  bronchial  ty[ic  witii  large 
moist  rales,  suggesting  cavity,  about  ninth  rib  and  two  inches  Irom 
spine.     Abdomen  negative. 


316  FOREIGN  BODIES  IN  BRONCHI  FOR  PROLONGED  PERIODS. 


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FORKIGN  P.ODIKS   I.N   liKONClII   l-dK  rROLOXGKD  PERIODS.  317 

Radiographs  taken  in  lirooklyn  showed  Ihe  nail  in  the  center  of  a 
large  shadow  that  iiickided  nearly  all  of  the  left  lung  (Fig.  195).  At 
the  Presbyterian  Hospital  the  author  passed  a  bronchoscope  and  encoun- 
tered a  large  quantity  of  very  foul  pus.  After  removal  of  this  and  the 
excision  of  granulations  the  nail  was  found  in  a  large  cavity.  There 
was  no  stricture  and  the  removal  presented  no  particular  difficulty.  The 
child  returned  to  Xew  VorU  the  next  evening.  Dr.  Moorehead  reported 
later  that  the  child  did  well  for  three  weeks,  his  condition  was  improved, 
and  his  cough  and  expectoration  very  greatly  diminished.  Suddenly 
about  a  month  after  the  nail  was  removed,  he  had  a  convulsion  and  on 
the  following  day,  two  more.  Complete  paralysis  of  the  left  arm,  left  leg 
and  left  side  of  the  face  developed  and  he  died  five  days  after  the  initial 


Frc.   196. — Drawinii  of  nail  removed   from  lung  oi  Edward   M.  by  oral  bron- 
choscopy without  anesthesia,  general  or  local. 

convulsion.  .A  conMillant  neurcjlogist  stated  that  it  was  undoubtedly  a 
case  of  embolism  of  the  middle  cereljral  artery.  Xo  autopsy  was  per- 
mitted. 

Remarks.  This  case  shows  clearly  that  removal  of  the  foreign  body 
cannot  be  expected  always  to  be  followed  by  recovery  in  a  case  with  an 
extensive  \irulent  pus  focus  in  the  lung.  The  emaciated  wretched  con- 
dition of  the  child  shows  the  havoc  that  can  be  wrought  by  a  foreign 
body  in  the  lung.  The  close  simulation  of  tuberculosis  might  be  very 
misleading  in  case  of  a  foreign  body  not  radiographically  \isible.  The 
source  of  the  embolus  might  have  been  the  lung  or  the  heart.  Occur- 
ring over  three  weeks  after  bronchoscopy  it  could  have  had  no  relation 
thereto. 


CHAPTER     XVII. 

Unsuccessful  Cases  of  Bronchoscopy  for 
Foreign  Bodies.* 

After  a  monotonously  long  series  of  successful  cases,  the  bronchos- 
copist  is  apt  to  think  there  are  no  limits  to  bronchoscopic  foreign  body 
removals.  Sooner  or  later,  however,  he  will  discover  that  there  are  very 
decided  limitations.  These  limitations  so  far  as  present  experience  shows, 
are  all  the  failure  to  find  a  small  body  that  has  entered  a  minute  bronchus 
far  down  and  far  out  toward  the  perijihery.  In  such  cases,  the  localiza- 
tion methods  of  the  author's  films,  Boyce  calipers,  fluoroscopy,  etc., 
having  failed,  the  question  arises  whether  it  is  advisable  to  incur  the  risk 
of  endoscopic  excision,  with  the  aid  of  two  fluoroscopes,  one  for  the 
lateral  and  another  for  the  vertical  plane.  Xaturallv  the  risk  of  such  a 
procedure  will  depend  upon  the  nature  of  the  tissue  inter\ening  between 
the  foreign  body  and  the  end  of  the  bronchoscope,  and  this,  in  turn,  will 
depend  upon  the  location  of  the  intruder.  With  foreign  bodies  in  the 
larger  bronchi  near  the  root  of  the  lung,  it  is  not  to  be  thought  of,  but 
here  endoscopy  is  rarely,  if  ever,  unsuccessful.  At  the  extreme  periph- 
ery of  the  lung  the  danger  is  less,  and  is  largely  concerned  with  the 
contingency  of  opening  a  vessel  that  will  permit  blood  to  be  retained  to 
break  down  later,  as  well  as  the  immediate  risk  of  hemorrhage.  The 
author  has  planned  such  an  operation  but  has  not  yet  encountered  an 
endoscopically  unsuccessful  case  of  foreign  body  so  located  that  the 
endoscopic  operation  seemed  to  involve  less  hazard  than  thoracotomy. 

Theoretically,  it  might  be  supposed  that  the  shortening  of  the  bron- 
chi that  takes  place  in  pneumothorax  might  be  sufficient  to  cause  the 
point  of  a  pin  to  emerge  from  the  invaded  bronchus  into  the  larger  one 
of  which  it  is  a  branch.  In  one  of  the  author's  cases  (Miss  J.),  this  did 
not  occur.  (Compare  Figs,  liiii  and  200.)  The  question  arises,  what 
shall  be  done  if  the  bronchosco])ist  fails  to  find  the  foreign  bodv  after 
having  used  all   the  methods  of  localization  mentioned?       The    writer 


♦Revised  from  author's  p,Tper  read  before  the  American  Larynsrolosical  .\s.so- 
ciation.  May,  1914. 


UNSUCCESSFUL  CASKS  OF   BRONCHOSCOPV.  I?!!) 

feels  that  duty  to  a  felhjw  creature  demands  that  at  least  one  other 
skillful  hronchoscopist  should  try  before  deciding  upon  either  leaving 
the  foreign  body  alone  to  nature,  or  sending  the  patient  to  the  general 
surgeon  for  thoracotomy.  Up  to  the  present  writing,  the  author  has 
had  five  failures  and  he  congratulates  himself  upon  his  not  having 
advised  either  of  these  alternatives  without  the  patient  having  the  bene- 
fit of  the  efiforts  of  another  bronchoscopist.  In  his  first  failure.  Prof. 
Killian  had  previously  failed,  and  the  author  had  with  him  at  the  time 
of  his  own  attempt,  Algernon  Coolidge,  Jr..  who  made  a  careful  search 
at  the  author's  request  after  the  author's  failure  to  find  the  foreign  body. 
In  the  second  case,  Cornelius  Coakley  had  previously  attempted  to  find 
the  foreign  body.  In  the  third  case,  Samuel  Iglauer  and  J.  W.  Murphy 
had  both  attempted  to  find  the  foreign  body,  and  in  the  fourth  case.  Dr. 
P.  M.  Hickey  had  attempted  to  find  the  foreign  body.  In  the  additional 
case  the  i^atient  was  taken  away  from  the  hospital  by  the  father,  who 
positively  refused  to  leave  it  until  another  bronchoscopist  could  be  called. 
In  the  four  cases  enumerated,  after  the  eitorts  of  the  expert  bronchos- 
copists  mentioned  had  failed  to  find  the  foreign  body,  the  author  felt 
that,  with  his  own  eft'orts  failing  also,  the  patient  had  been  given  the  bene- 
fit of  everything  that  bronchoscopy  had  to  oft'er,  and  it  remained  to  con- 
sider the  next  step. 

hi  deciding  this  (|UCstion,  it  is  first  necessary  to  consider  what  will 
hap])eii  if  the  foreign  body  is  allowed  to  remain.  This  has  been  gone 
over  analytically  by  Delavan.  Roe,  Wood  and  others  in  the  pre-bronchos- 
copic  days  and  bv  Clayton,  Clark  and  Marine  more  recently,  as  else- 
where mentioned.  liecausc  of  its  brilliant  achievements,  bronchoscopy 
has  been  universally  accepted,  and  for  that  reason,  but  very  few  foreign 
bodies  have  remained  in  the  bronchi  when  their  presence  was  known. 
Th.e  cases  where  bronchoscop\-  has  failed  have  been  limited  to  cases  in 
which  the  foreign  body  could  not  be  foiuid.  and  these  have  invariably 
been  very  small  bodies  far  down  and  far  out  at  the  periphery.  In  this 
location,  the  most  jirobable  result  is  that  an  abscess  will  form  and  that 
it  will  burst  through  into  the  pleural  cavity.  It  then  becomes  a  question 
whether  thoracotomy  shall  be  done  at  once  upon  the  failure  of  bronchos- 
copy or  whether  the  abscess  formation  with  invasion  of  the  pleura  shall 
he  av.'aitcd.  The  chief  arguments  against  waiting  are  that  the  patient 
may  not  survive  sufficiently  long  for  the  development  of  the  abscess  and 
the  reaching  of  the  pleura.  Furthermore,  the  foreign  body  may  not 
follow  the  abscess  into  the  pleural  cavity  as  seen  in  the  case  of  Mrs.  K., 
rejjorted  in  a  jirevious  chapter.  In  that  instance  the  foreign  bod\-  was 
easilv  removed  through  the  nKJUlh  because  it  was  large  and  consequently 
easy  to  find.     Because  of  its  large  size,  also,  it  had  not  reached  the  ])oint 


320  UNSUCCESSFUL  CASES  OF    BRONCHOSCOPY. 

near  the  periphery  after  the  original  accident,  and  it  took  twenty-six 
years  for  the  abscess  to  reach  the  pleura.  During  the  wait  for  an  ab- 
scess to  reach  the  pleural  cavit\',  there  is.  of  course,  the  possibility  that 
the  foreign  body  may  slough  loose  and  be  coughed  out.  Such  a  possibil- 
ity is  remote  in  any  case  and  in  case  of  some  bodies,  as  pins,  it  is  impossi- 
ble. Furthermore.  (  Delavan.  IJib.  ]ii7  )  lesions  may  be  established  which 
will  result  in  the  death  of  the  patient  even  after  the  foreign  body  has 
been  gotten  rid  of.  (See  case  of  Edward  M.,  in  Chapter  X\'I).  Na- 
ture can  cure  appendicitis  and  can  amputate  a  limb,  but  no  one  know- 
ingly takes  the  risk  of  waiting.  Apropos  of  this,  a  very  interesting  col- 
lection of  thirty-two  cases  is  reported  by  Clarke  and  Marine,  in  which 
gang'-ene  of  the  lung  followed  the  aspiration  of  a  foreign  body.  Their 
analysis  is  as  follows:  "Of  thirty-one  cases,  the  foreign  body  was  a  tooth 
twice,  a  pin  once,  a  piece  of  wood  once,  a  button  twice,  a  head  of  grain 
or  grass  seven  times,  a  bit  of  evergreen  twice,  a  fruit  stone  twice,  a  bone 
ten  limes  :  not  mentioned,  four  times  :  that  it  occurretl  with  ei|ual  freque:ic\ 
in  adults  and  children  ;  that  it  remained  in  the  bronchus  before  gangrene 
set  in  from  four  days  to  five  months,  usually  under  three  weeks.  Gan- 
grenous process  lasted  from  three  days  to  four  years,  most  frequently 
from  two  to  four  weeks :  the  outcome  was  death  in  twenty-one  cases, 
reco\ery  after  thoracotom\-  in  two,  and  spontaneous  recover\^  in  four 
cases.  The  foreign  body  was  coughed  up  in  five  cases,  four  of  which 
subsequently  died  and  only  one  recovered."  To  these  statistics  is  to  be 
added  the  case  that  Clarke  and  ^Marine  themselves  observed,  in  which  a 
man  died  of  pulmonary  gangrene  seventeen  days  after  aspirating  a  frag- 
ment of  bone,  death  occurring  two  days  after  the  first  appearance  of 
putrid  expectoration,  \iewing  the  question  impartially  from  all  sides, 
the  author  believes,  first,  that  large  foreign  bodies,  which  necessarily 
stop  in  the  trachea  or  larger  bronchi,  can  always  be  removed  by  bron- 
choscopy, therefore,  thoracotomy  is  absolutely  out  of  consideration.  In 
case  of  small  foreign  bodies  far  down  and  far  out  at  the  periphery,  after 
two  expert  bronchoscopists  have  failed  to  find  the  foreign  body,  the  in- 
truder should  be  removed  by  external  operation,  and  the  sooner  after  the 
bronchoscopic  failure,  the  better,  because  of  the  usually  early  develop- 
me:it  of  septic  processes  around  an  aspirated  foreign  bod\-.  .Modern 
de\elopments  and  especia!l\'  the  intratracheal  insufflation  anesthesia, 
originated  by  IVIeltzer  and  Auer,  and  developed  by  Elsberg,  Janewav  and 
others.  ha\e  ])laced  thoracotomy  on  a  plane  never  before  obtained,  and 
while  the  pleural  shock  remains,  the  mortality  is  very  much  decreased  and 
the  operation  has  reached  the  stage  where  it  is  justly  entitled  to  con- 
sideration in  cases  where  two  expert  lironchoscopists  have  failed.  It  is 
certainly  preferable  to   taking   the  chances  of   lea\ing  the   foreign   body 


UNSUCCESSITL  CASES  01*   BRONCHOSCOPY.  321 

alone.  Formerly,  there  was  great  difficulty  in  finding  the  foreign  body 
after  the  lung  was  open,  but  in  the  modern  oiieration  with  the  very  large 
flap  and  ample  opening,  where  the  entire  lung  can  Ije  handled,  the 
chances  of  not  being  able  to  find  the  foreign  body  are  very  small.  In 
the  event  of  a  foreign  liodv  reaching  the  ])leura  either  with  or  without 
pus.  it  should  be  immediately  removed  by  pleuroscopy  (q.v. )  or  by 
thoracotomy,  without  waiting  for  adhesive  pleuritis. 

As  to  the  details  of  thoracotomy,  the  author  has  never  done  the 
operation  and  ne\er  will.  Me  l)egs.  however,  to  make  four  stiggestions. 
1.  Tn  these  days  of  insulilation  intratracheal  anesthesia,  the  bronchos- 
copist  is  of  no  use  in  the  operation.  .\nv  aid  in  localization  he  may 
be  able  to  afford  is  better  given  verbally  bv  naming  the  approximate 
location  of  the  invaded  bronchus.  2.  The  best  method  of  visceral  localiza- 
tion is  by  the  author's  transparent  films,  because  after  collapse  of  the 
lung,  the  relation  of  the  visceral  to  the  bony  anatomy  is  entirely  changed. 
To  know  the  bronchus  invaded  simplifies  the  search.  3.  The  best  method 
of  location  of  the  osteoplastic  flap  is  by  the  method  of  Lewis  Gregory 
Cole  and  other  expert  radiographers.  4.  As  the  infective  risk  is  slight, 
and  the  ojjcrative  risk  is  greater  than  the  s(|tiare  of  the  duration  of  the 
operation,  the  thoracotomy,  especially  in  children,  should  be  done  without 
gloves.  However  trained  the  gloved  touch,  no  one  can  argue  that  a  i)in 
cannot  be  found  c|uicker  in  the  lung  without  gloves  than  with  them,  espe- 
cially in  the  case  of  infants  and  children  where  the  largest  possible  open- 
ing will  not  permit  the  use  of  llie  whole  hand.  Extraordinary  care  in 
preparation  of  the  han<U  will  make  the  hands  reasonabh'  safe  from  in- 
fecti\e  risk  in  this,  the  niily  iipi-r.'ition  in  surgery  where  gloves  ma\  kill 
the  i)atient 

THK    ArTUOU's    UNSUCCESSFUL   CASES. 

Of  the  author's  five  unsuccessful  cases,  one  was  before  the  dcvel- 
oi)ment  of  bronchoscopy  to  a  reasonable  degree  of  efficiency,  and  four 
cases  have  occurred  since.  All  were  failures  to  find  a  small  foreign  bo(l\- 
in  a  minute  bronchus  tar  down  and  far  out  toward  the  peripherv.  The 
author  li()i)es  that  his  el.sewhere  mentioned,  recently  perfected  means  of 
localization  will  in  the  future  be  of  assistance  in  lessening  the  number 
.if  inilindalile  foreign  bodies,  though  these  methods  were  used  in  the  last 
case  of  the  four  and  failed  to  enalde  success.  In  each  of  these  four 
cases  removal  had  been  j)reviously  attempted  by  skillful  bronchoscopists 
of  large  ex|)erience.  Had  the  .luthor  .done  failed  on  these  four  cases 
he  woulfl  feel  that  they  were  personal  failures.  On  the  contrary  they 
should  be  cf)nsidercd  as  failures  of  brouchoscopy  and  should  be  analyzed 
as  such  in  order  that  br()ncho>co])\ .  like  ;uiy  other  de])artment  of  medi- 
cal science,  shall  profit  li\   its  f;iilures. 


322 


UNSUCCESSFUL  CASES  OF   BRONCHOSCOPY. 


Fig.  197. — Radiograph  of  pin  in  right  hing  of  a  girl,  aged  eighteen  years. 
The  pin  could  not  be  toimd  at  bmnchoscopy.  (Mis?  C).  Lower  radiograph 
shows  how  the  pin  had  migrated  towards  the  pleura  at  the  end  of  two  years. 


UNSUCCESSFUL  CASES  OF    BKONCIIOSCOPV. 


323 


FiK.  Kjy.— Kailiograplis,  anUT"i)nsicrii)r  ami  latiral  (I'y  l*r,  l.angc  ul  Cincin- 
nati) showing  pin  in  posterior  t)rani.-h  of  left  inferior  lobe  hronclnis  of  Miss  J. 
The  |]in  is  rctoudied   for  clearness. 


324 


UNSUCCESSFUL  CASES  OF  BRONCHOSCOPY. 


Aliss  C,  aged  eighteen  years,  referred  by  Dr.  Edward  S.  Bacon. 
Patient  had  aspirated  a  pin  four  weeks  previously.  No  cough,  expectora- 
tion or  other  symptoms.  Dr.  Bacon  saw  the  pin  endoscopically  in  the 
right  bronchus  immediately  after  the  accident,  but  was  unable  to  dis- 
impact  it  with  all  the  traction  he  deemed  safe.  A  few  weeks  later  the 
pin  was,  radiographically,  found  to  have  gradually  worked  its  way  to- 
ward the  periphery  of  the  lung.  P^rof.  KiUian,  who  was  the  guest  of 
the  American  Laryngological  Association  at  the  time,  made  an  unsuc- 
cessful bronchoscopic  attempt  at  removal.  A  few  weeks  later  the  author 
passed  a  bronchoscope.  Ether  was  used  at  the  start,  but  was  discontinued 
after  about  fifteen  minutes.    The  author  was  honored  by  the  presence  of 


Fig.  198. — Radiograph  of  Mrs.  S.  showing  pin  in  posterior  branch  of  inferior 
lobe  bronchus.  Pin  could  not  be  found  at  bronchoscopy.  (Retouched  for  clear- 
ness). 


Algernon  Coolidge,  ]r.,  one  of  the  pioneer  bronchoscoi)ists.  Neither  of 
US  could  find  the  pin  which  was  plainly  exidcnt  in  the  radiograph  (Fig. 
in;).  \\'e  found  the  bronchi  of  the  left  lung  all  normal  in  appearance. 
The  mucosa  of  all  the  right  bronchi  was  congested  and  swollen.  The 
orifices  of  the  branch  hnjnchi  were  diminished  to  about  half  tlie  normal 
size,  as  estimated  by  comi)arison  with  the  opposite  side.  As  Dr.  Coolidge 
pointed  out,  there  were  no  localizing  signs,  such  as  emerging  pus,  to  lead 
one  to  suspect  one  bronchus  more  than  another.  A  few  were  care- 
fully explored  by  the  author  with  negative  results.  The  search  occupied 
about  an  hour  and  a  half.  There  was  no  reaction  and  the  patient  left 
the  hospital.     Her  health  was  fair  at  the  end  of  a  year.  Occasional  "jag- 


UNSl'CCESSI-UL  CASIiS  Dl''  BRONCHOSCOry. 


335 


ging"  pains  were  felt  and  there  was  some  cough.       At  the  last  rejiort 
the  pin  was  gradually  working  toward  the  pleura. 

Mrs.  S.,  aged  forty-three  years.  Seen  in  consultation  with  Dr. 
Cornelius  Coakley,  at  St.  Luke's  Hospital,  New  York  City.  Patient 
had  a  strumic  stenosis  for  which  a  tracheotomy  had  been  done  by  Dr. 
Far(|uar  Curtis.  A  pin  had  been  aspirated  into  the  bronchus  two 
months   before   admission,   and   the   excellent    radiographic   work   of   the 


Fig  200. — Radiograph  showing  displacement  of  pin  after  pneumothorax.  (Case 
of    Miss  J).      Ketoiiclied    for   clearness.      (Author's   case). 


hospital  radiograjihcr  had  located  the  pin  |ioslcri(jrly  very  low  in  tlie 
left  lung  iTMg.  1!!S).  13r.  Coakley  had  made  a  careful  and  skillful 
search  without  finding  the  ])in.  The  author  was  e(|iially  unsticccssfiil. 
There  were  no  localizing  signs.  In  one  of  the  bronchi  the  author  thought 
he  felt  contact  nf  the  pin  but  it  conld  nut  be  suflicientlv  conlirnicd  to 
justify  using  the  f(:rcci:s.  The  jiaticnt  died  one  and  one-half  years 
later,  after  refusing  external  operation  for  pulmonary  abscess. 


326 


UNSUCCESSFUL  CASES  OF   BRONCHOSCOPY. 


Remarks.  In  passing,  it  may  be  said  that  tlie  extreme  posterior  loca- 
tion of  the  pin  and  the  presence  of  a  tracheotomic  wotmd  ( made  for 
strumic  stenosis )  led  the  author  thoroughly  to  test  out  the  supposed  ad- 
vantages of  tracheotomic  or  '"lower  bronchoscopy."  He  could  discover 
no  advantage  whatever  as  compared  to  oral  bronchoscopy  with  the  head 
in  the  Boyce  position.  This  was  in  1908  and  the  author  has  not  done  a 
tracheotomic  bronchoscopy  for  a  foreign  body  since. 

]\Iiss  J.,  aged  nineteen  years,  referred  by  Dr.  Samuel  Iglauer  for  a 
pin  in  a  posterior  branch  of  the  left  inferior  lobe  bronchus  as  shown  by 
an  excellent  radiograph  (Fig.  1!);))  by  Dr.  Lange,  of  Cincinnati.  (See 
report  of  Dr.  Iglauer,  Bib.  221.)  Drs.  Iglauer,  Mithoefer  and  J.  W. 
Murphy,  all  endoscopists  of  large  experience,  had  failed  to  find  the  pin 


Fig.  201. — Radiugrapli  shu\vin,u  a  pin  almost  at  tlic  pt-riplKTy  of  \\k  lung  of  a 
child  of   i6  months.      (Author's  case). 


bronchoscopically.  The  author  made  two  bronchoscopic  searches,  one 
with  ether  and  one  without.  He  could  not  find  the  pin  nor  any  pathologic 
signs  of  its  presence.  Twenty-four  hours  later  pneumothorax  was  evi- 
dent. The  pin  was  displaced  and  tilted  as  shown  in  Fig.  200.  Another 
search  was  made  but  it  was  also  unsuccessful.  Dr.  J.  Hartley  Ander- 
son removed  the  pin  by  thoracotomy,  making  a  large  osteoplastic  flap 
posteriorly.  The  patient  made  a  good  recovery  and  in  a  few  weeks  the 
lung  had  expanded. 

Carol  H..  aged  sixteen  months,  referred  to  the  author  by  Dr.  P.  ]M. 
Hickey,  for  a  ]iin  in  a  dorsal  branch  of  the  left  inferior  lobe  bronchus 
(Fig.  •?oii).  Two  bronchoscopies  by  Dr.  Hickey  had  failed  to  find  the 
[lin  and  the  autlior  was  equally  unsuccessful.  .\  general  surgeon,  by  a 
([uick  and  skillful  thoracotomy,  removed  the  pin.  'J"he  ]iatient  succumbed 
twentv-four  hours  later. 


UNSUCCKSSFUL  CASKS   OV    HROXCHOSCOPV.  337 

After  the  foregoing  was  written  and  while  this  book  is  in  press  the 
author  has  had  another  unsuccessful  case.  Drs.  Henry  Janeway,  Harmon 
Smith  and  Sidney  Yankauer  had  failed  to  find  a  metallic  foreign  body 
which  showed  plainly  in  excellent  lateral  and  anteroposterior  radiographs 
(by  Dr.  A.  S.  Holding )  and  they  honored  the  author  by  calling  him  to  the 
case.  Bronchoscopy  by  the  author  at  the  New  York  General  Memorial 
Hospital  was  equally  unsuccessful  in  seeing  the  foreign  body.  Dr.  A.  S. 
Holding  fluoroscopically  saw  the  intruder  upward  and  outward  and  for- 
ward from  the  bronchoscopic  tube-mouth  when  the  latter  was  in  the  left 
upper-lobe  bronchus,  thus  definitely  locating  the  foreign  body  in  an  an- 
teriorly ascending  branch  of  tlie  left  ui>per-lobe  bronchus.  A  subsequent 
thoracotomy  confirmed  the  localization ;  liut  the  patient  succumbed. 

From  this  case  it  is  fair  to  conclude  that  a  foreign  body  may  get  so 
far  toward  the  periphery  in  the  upper  lobe-bronchus  as  to  be  beyond  the 
limitations  of  bronchoscopy.  (Hit  of  six  upper  lobe-bronchus  cases,  in 
the  author's  experience,  this  is  the  only  one  that  invaded  so  far  as  to  be 
beyond  reach. 


CHAPTER     XVIII. 

Foreign  Bodies  in  the  Esophagus. 

Part  of  this  subject  was  consitlered  in  a  previous  chapter  (XII)  on 
the  general  subject  of  foreign  bodies  in  the  air  and  food  passages.  A 
number  of  important  points  require  additional  consideration. 

Etiology.  In  the  esophagus  the  lodgment  of  foreign  bodies  is  in- 
fluenced by  five  factors. 

J.     The  shape  of  the  foreign  body   (pointed,  rough,  etc.). 

;!.     Resiliency  of  the  foreign  body   (safety  pins,  etc.). 

3.     The  size  of  the  foreign  body  (a  large  meat  bolus). 

L  Narrowing  of  the  esophagus,  spasmodic  or  organic,  normal  or 
pathologic. 

5.     Paralysis  of  the  normal  esophageal  propulsory  meclianism. 

The  modes  of  action  of  the  foregoing  list  of  causes  are  self-evident, 
but  numbers  three  and  five  require  further  consideration.  As  a  rule, 
when  ordinary  food  lodges  in  the  esophagus,  there  is  a  strong  suspicion 
that  there  is  some  organic  trouble  present,  such  as  compression  by  an 
aneurysm,  or  a  malignant,  or  a  cicatricial  or  a  spasmodic  narrowing. 
In  one  of  the  author's  cases  a  deckhand,  eating  a  very  hurried  meal, 
had  an  enormous  Ijohis  of  meat  lodge  in  the  esophagus  at  the  crossing  of 
the  left  bronchus,  completely  occluding  the  gullet.  The  pyriform  sinuses 
were  full  of  secretions  and  a  large  quantity  of  secretions  was  brought 
through  the  aspirator  before  the  esophagoscope  reached  the  bolus  at  the 
crossing  of  the  left  bronchus.  After  the  esophagoscopic  removal  of  the 
meat,  the  esophagus  seemed  normal  and  free  from  compression  or 
stricture.  The  man  had  never  had  any  trouble  in  swallowing  before, 
and  has  had  none  since,  although  three  years  have  elapsed.  It  seems 
quite  evident  that  it  was  only  the  enormous  size  of  the  bolus  which 
caused  it  to  lodge,  and  it  is  probable  that  it  passed  the  cervical  narrow- 
ing in  more  or  less  elongated  form  but  broadened  out  as  it  reached  the 
thoracic  esophagus,  during  the  negative  i)ressure  of  an  inspiration,  and 
in  this  more  expanded  form,  it  completely  occluded  the  narrowing  at 
the    crossing   of    the    bronchus.      Paralysis    of    the    esophagus,    at   first 


FoKKIGN    BODIES  IN  THE  ESOPHAGUS. 


32!) 


thought,  might  be  thought  not  to  interfere  with  the  downward  passage 
of  any  substance  and  yet  even  liquids  will  not  go  down  a  paralyzed  esoph- 
agus as  mentionLMi  under  diseases  of  the  esophagus.* 

Why  do  foreign  bodies  in  the  esofrhagiis  lodge  most  frequently  at 
certain  localities?  As  in  the  air  passages,  the  greater  frequency  of 
lodgment  of  foreign  bodies  in  certain  localities  is  governed  by  factors 
which  mav  be  classed  in  three  main  divisions: 

].      (a)  The  size  and  shape  of  the  foreign  body,  whether  long,  broad, 


Fig.  202. — Schematic  illustration  of  the  site  of  lodgment  in  135  cases  of  for- 
eign body  in  the  esophagus,  from  statistics  collected  from  litirature  by  H.  Burger. 
Th.,  thyroid  cartilage.  Cr.,  cricoid  cartilage.  M.,  manubrium.  Cohnnn  A  shows 
the  location  in  those  cases  where  relation  to  the  spine  was  mentioned.  Column  B 
shows  the  position  of  the  intruder  when  this  was  given  in  relation  to  the  thyroid, 
cricoid,  manubrium  or  sternum.  In  column  C  are  indicated  the  cases  wdiere  the 
localization  was  given  in  more  general  terms.     (After  Sir  St.  Clair  Thomson). 


pointed,  angular,  disk-like,  etc.     ( b)  Its  surface,  whether  rougli  or  smooth, 
(c)  Its  i)hysical  prii]ierlies,  resiliency,  ])lasticity,  absorbtivity,  etc. 

2.  Tlie  anatomic  peculiarities  of  the  various  localities,     (a)  Angles, 
arcs,     (b)  Fixed  and  moliU-  narrowings. 

3.  Paralysis  of  the  eso])hageal  i)ropulsory  mechanism. 

An  interesting  tabulation  f)f   reported  cases  of  eso])hageallv   loiigcd 
foreign  bodies  is  shown  schematicallv  in  I'ig.  'i^^'i,  winch   is  rc|>r(iiluced 

•Aei'  as  an  etiolosric  fuctor  i.s  .shown  by  the  fact  that  of  the  iiulhor's  4;)  cases 
of  bones  in  the  e.«ophngu8  aU  but  2  were  in  adult.s;  wheien.-;,  of  38  cases  of 
esophaKcally  Iodised  coin.-;,  in  thi-  iiuthor'.s  experience,  jill  were  In   children. 


330  FOREIGN  BODIES  IN  THE  ESOPHAGUS. 

from  Sir  St.  Clair  Thomson's  excellent  book.  Of  course,  a  considerable 
latitude  for  inaccuracy  must  be  allowed,  because  of  the  necessarily  inac- 
curate localization  in  perhaps  the  majority  of  published  reports.  Never- 
theless the  grouping  of  almost  all  of  the  cases  in  the  upper  third  of  the 
esophagus  is  very  striking  and  coincides  with  the  experience  of  all 
esophagoscopists.  Most  of  the  very  few  cases  of  lower  lodgment  en- 
countered have  been  pushed  down  by  blind  methods.  \'arious  reasons 
have  been  assigned  for  the  lodgment  of  almost  all  foreign  bodies  in  the 
upper  third ;  but  none  of  them  appeal  to  the  author  as  being  satisfactory. 
His  own  opinion  is  that  it  is  a  physiological  narrowing  due  partly  to 
spasm,  but  mainly  to  the  fact  that  the  cervical  esophagus  is  normally 
collapsed  and  is  not  subject  to  the  negative  pressure  that  expands  the 
intrathoracic  portion  of  the  esophagus.  Xot  only  is  the  musculature  of 
the  cervical  esophagus  more  powerful  in  its  contractions,  but  it  is  a  col- 
lapsed tube.  The  mediastinal  esophagxis,  on  the  contrary,  is  being 
pulled  open  and  thus  the  foreign  bodies,  unless  of  verj-  large  size,  are 
relieved  and  readily  find  their  way  downward.  Against  the  theory  that 
it  is  simply  the  quiescent  narrowness  of  the  cervical  esophagus  that 
holds  the  foreign  body,  is  the  fact  that  there  is  plenty  of  room  for  quite 
a  large  esophagoscope  to  override  the  foreign  body  and  pass  it  without 
the  inexperienced  operator  being  able  to  see  the  foreign  body  at  all.  If 
the  esophagus  were  narrow  at  the  point  and  retaining  the  foreign  body 
only  by  tiie  smallness  of  its  lumen,  one  would  suppose  this  overriding 
could  not  occur.  ( )ne  point  that  indicates  that  there  is  a  large  element 
of  spasm  in  the  lodgment  of  foreign  bodies  in  the  esophagus,  is  the  fact 
that  operators  who  use  general  anesthesia  have  a  much  larger  propor- 
tion of  foreign  bodies  escape  downward  than  those  who  do  not.  Since 
abandoning  anesthesia  for  the  removal  of  esophageally  lodged  foreign 
bodies  (except  in  the  case  of  very  large  bodies)  the  author  has  not  had 
a  single  case  of  escape  of  the  intruder  downwards  during  esophagoscopy. 
From  esophagoscopic  observation  in  other  than  foreign  body  cases  one 
would  suppose  that  foreign  bodies  would  lodge  in  the  clutch  of  the  crico- 
pharyngeus  but,  in  the  author's  experience,  this  is  not  nearly  so  frequent 
a  locality  as  the  upper  thoracic  aperture.  We  may  conclude,  then,  that 
it  is  the  physiological  narrowing  at  the  upper  thoracic  aperture.  This 
narrowing  disappears  under  anesthesia  in  the  recumbent  position  and 
is  not  demonstrable  by  cadaveric  anatomy ;  hence,  probably  is  partly 
muscular  and  partly  the  crowding  of  the  adjacent  viscera  into  the  fixed 
and  narrow  upper  thoracic  aperture.  It  is  probable  that  the  anatomic 
changes  associated  with  the  phylogenetically  late  upright  posture  of  man 
is  associated  with  the  physiological  narrowing  which  causes  foreign 
bodies  to  lodge  at  the  upper  thoracic  aperture. 


1-OKEIGN    BdDIKS   IN  THE  ESOPHAGUS. 


331 


Syinf'tonis  of  forc'ujn  body  in  the  esophagus,  and  indications  for 
esophoi/oscopy.  It  would  be  a  waste  of  valuable  space  extensively  to 
consider  here  the  symptoms  of  esophagealh'  lodged  foreign  bodies.  They 
form  no  basis  for  the  determination  as  to  whether  an  esophagoscopy 
should  he  done  or  not.  for  symptoms  may  be  entirely  absent,  even  in 
cases  of  rather  large  intruders.  If  the  patient  has  swallowed  a  foreign 
body,  that  body  must  be  found  in  the  anatomy  or  in  the  stools.  A  very 
small  foreign  body  may  cause  regurgitation  and  complete  inability  to 
swallow  even  water.    This  occlusion  may  be  due  to  spasm,  swelling  of  the 


Fig.  20,^. — Lateral  r;'.(linj;raph  sliowins  lodgment  of  a  collar  Inittoti  in  the 
esophagus  at  the  usual  location,  at  the  upper  thoracic  aperture — not  at  the  crico- 
pharyngcal  narrowing.    Locatiim  corroborated  at  esophagoscopy.     (Author's  case). 


esophageal  walls,  or  to  augmentation  of  the  size  of  the  intruder  by  ex- 
pansir)n  with  absorbed  inoisture,  or  by  accumulation  of  food  about  the 
intruder.  Coins  mav  cause  intermitlciit  occlusion  liy  change  of  position. 
They  usually  permit  food  to  pass  and  they  often  show  a  bright  streak 
down  the  center  third  of  one  or  both  sides  where  the  passing  food  has 
kept  the  surface  bright,  while  at  the  lateral  thirds,  which  are  more  or 
less  buried  in  the  folds  of  the  mucosa,  corrosion  or  oxidation  darkens 
the  coin.  This  is  most  noticeable  in  silver  coins,  in  which  the  lateral 
thirds  arc  darkened  by  the  formation  of  silver  sulphide  on  the  surface. 
("See   illustrations   of   coins    in   case    reports    in    a    sulisequent    chai)ter.) 


332  KORKIGN   B<5DIES  IN  THE  ESOPHAGUS. 

This  shows  that  foods  pass  flat  objects  like  coins  quite  readily  as  a 
rule.  Occasionally,  however,  occlusion  is  complete  from  the  outset. 
Carpenter  (Bib  73)  reports  one  such  case  in  which  nothing  could  be 
swallowed  in  the  three  days  between  lodgment  and  esophagoscopic  re- 
moval. On  the  other  hand  a  foreign  body  which  has  remained  long  in 
situ  may  give  rise  to  no  sym])toms  whatever  and  if  the  lodgment  has  been 
in  childhood,  growth  and  development  may  possibly  permit  the  child  to 
swallow  sufficiently  well  that  no  difficulty  is  noticeable,  as  in  a  case  re- 
ported by  W.  G.  Porter,  in  which  a  half -penny  had  remained  in  the 
esophagus  of  a  child  for  eight  years,  who  then  was  brought  for  in- 
definite gastric  symptoms,  not  for  dysphagia.  Dyspnea  may  be  a  symp- 
tom of  an  esophageally  lodged  foreign  body.  In  one  of  the  author's 
cases  a  large  foreign  body  produced  so  much  compression  of  the  trachea 
that  the  trachea  was  explored  first  and  found  to  be  very  much  stenosed 
because  of  the  forward  pressure  on  the  membranous  party  wall  bv  the  in- 
truder. Cough  is  one  of  the  symptoms  of  foreign  body  in  the  esophagus 
that  must  not  be  forgotten.  It  may  be  due  to  reflex  irritation,  to  se- 
cretions overflowing  into  the  laryn.x  from  the  occluded  esophagus,  or  to 
perforation,  traumatic  or,  later,  ulcerative,  of  the  party  wall  causing 
leakage  of  food  or  secretions  into  the  trachea.  In  one  of  the  author's 
cases,  elsewhere  herein  reported,  the  mother  said  the  child  "coughed 
until  it  vomited."  What  really  happened  was  the  leakage  of  the  nurs- 
ling's focd  thrnugh  tlie  ulcerative  foreign  bodv  fistula  from  the  esophagus 
into  the  trachea  resulting  in  the  coughing  up  of  the  milk.  In  foreign 
body  cases  in  which  there  is  comjilete  obstruction  the  author's  symptom 
of  esophageal  occlusion  may  be  present.  It  onsists  in  the  pyriform 
sinuses,  one  or  both,  being  filled  with  secretion  as  noted  on  indirect 
mirror  examination  in  the  erect  posture.  This  is,  of  course,  a  symptom 
only  of  occlusion,  not  necessarily  by  a  foreign  body.  It  is  due  to  re- 
tention of  fluids  which  fjtherwise  are  constantly  draining  down  through 
the  esophagus. 

The  localization  of  the  foreign  body  as  to  whether  it  is  in  the 
esophagus  or  in  the  air  passages  is  considered  under  the  head  of  bron- 
choscopy for   foreign  bodies. 

Prognosis.  A  foreign  body  lodged  in  the  esophagus  may  prove 
quickly  or  slowly  fatal  or  may  remain  for  many  years  if  its  size,  shape 
and  position  permit  food  to  pass.  E.  A.  Peters  reports  the  case  of  a 
man  dying  two  hours  after  a  tracheotomy  done  for  edema  of  the  glottis, 
secondary  to  hemorrhage  down  along  the  spine,  from  the  ]iuncture  of  the 
jugular  vein  by  a  pin  swallowed  with  food.  Adelman  cites  nine  cases 
and  Chiari  twenty-one  cases  of  perforation  of  the  aorta  by  foreign  bodies 
in  the  esophagus.     The  perforation  may  be  shortly  after  the  lodgment. 


I'dUKIGN    UODIES   KN  THE  lC.S(jr>H AGUS. 


333 


in  the  case  of  sharp  bo<Hes,  such  as  pins,  needles  and  sharp  bones ;  or 
more  slowly  by  erosion  and  ulceration.  Many  cases  of  foreign  bodies  in 
the  esophagus  have  been  quickly  fatal  through  perforation  and  septic 
mediastinitis.  Many  others  have  caused  death  through  suppuration  ex- 
tending to  the  trachea  with  consetiuent  edema  and  asphyxia.  In  cases 
of  [irolonged  sojourn  of   the   foreign  body  in  the   esophagus   thickening 


Fir,.  205. — kadionrapli  ol  forcis^n  body  (cuff  link)  part  oi  which  had  ulcerated 
through  from  the  esophagus  into  the  trachea  of  a  three  months  old  infant.  Re- 
moved partly  by  oral  lironchoscopy  and  partly  by  oral  esophagoscopy  witlunu  anes- 
thesia, general  or  local.     (.Author's  case). 


;nid  bypcrpl.'isia  of  the  esophageal  wall  result  from  nature's  effort  to 
])rotect  the  surrounding  tissues.  Sooner  or  later,  however,  if  not  re- 
moved, the  foreign  body  causes  death.  livery  large  museum  has  speci- 
mens of  this  kind,  .nid  ibc  mcjst  fre(|uentl\'  seen  foreign  body  is  the 
artificial  denture.  The  foregoing  remarks,  iiowever,  api)ly  cliicHy 
to  the  i)re-csoi)hagoscoi)ic  days.     To-day,   with  the  radiograph  and  the 


334  FOREIGN   BODIES   IN  THE   ESOPHAGUS. 

esopliagoscope,  foreign  bodies  are  discovered  and  promptly  removed. 
Dr.  D.  Braden  Kyle  reports  a  very  remarkable  case  in  which  he  ver\ 
skillfully  removed  an  artificial  denture  that  had  been  in  the  esophagus  for 
seventeen  years  (Fig.  2\~>).  The  patient's  condition  was  very  serious, 
and  but  for  the  timely  work  of  Dr.  Kyle,  the  patient  would  have  suc- 
cumbed. Perforation  of  the  upper  esophagus  may  result  in  cervical 
cellulitis  of  varying  degrees  of  intensity.  Abscess  may  result  in  any 
of  the  surrounding  tissues,  either  from  direct  infection  or  from  secondary 
necrosis  of  the  tracheal  or  laryngeal  cartilages  from  infective  perichon- 
dritis. One  such  case  was  referred  to  the  author  by  Dr.  Greenfield  Sluder 
for  an  opinion.  A  tooth  brush  bristle  and  a  bit  of  necrotic  cartilage 
were  discharged  from  an  abscess  at  the  mouth  of  the  esophagus  of  a 
physician  of  about  forty  years  of  age,  after  a  number  of  years  of  ill 
health.  The  fistula  is  still  unhealed.  Joseph  White  (Bib.  573)  reports 
a  similar  case  followed  by  laryngeal  stenosis.  Many  cases  are  fata! 
within  a  short  time  from  perforation  and  mediastinal  abscess.  The 
author  has  had  two  cases  in  which  a  foreign  body  ulcerated  through  from 
the  esophagus  into  the  trachea.  One  of  these  has  been  reported  ( Bib. 
269).    The  other  one  is  as  follows: 

Cuff  link  that  ulcerated  from  the  esophagus  into  the  trachea.  Infant 
C,  aged  three  months.  Referred  by  Dr.  J.  A.  Sullivan.  Parents  said 
child  "coughed  until  it  vomited."  Dr.  Sullivan  was  about  to  prescribe 
for  the  bronchopneumonia  present  when  the  parents  said  they  had 
missed  a  cuff  link  for  six  weeks  before  and  notwithstanding  this  in- 
definite statement  and  the  age  of  the  child  (only  six  months  at  the 
time),  the  doctor  sent  the  patient  to  Dr.  George  C.  Johnston  who  found 
the  cuff  link  radiographically  (Fig.  205)  and  referred  the  case  to  the 
author.  As  the  symjitoms  seemed  altogether  tracheo-bronchial,  the 
author  passed  a  lironchoscope  first  and  found  the  smaller  part  of  the 
button  in  the  trachea  with  the  stem  passing  backward  towards  the  esoph- 
agus. ^^'ithdrawing  the  bronchoscope  the  author  passed  an  esopliago- 
scope and  found  the  larger  part  of  the  button  in  the  esophagus  with 
the  stem  passing  forward  toward  the  trachea.  (Jn  re-examination  with 
the  bronchoscope  it  was  found  that  the  smaller  end  of  the  button  was 
loose  on  the  stem.  With  forceps  it  was  soon  twisted  ot^'  and  withdrawn 
through  the  glottis  w^ith  the  forceps  and  bronchoscope.  The  esophago- 
scope  was  introduced  into  the  esophagus  and  the  larger  portion  of  the 
button  with  the  stem  was  removed  without  difficulty  (Fig.  206).  The 
tem]3erature  which  had  ranged  about  103°  before  the  broncho-esophagos- 
copy  remained  about  the  same  for  about  a  week  and  then  slowly  and 
gradually  subsided.  One  year  later  the  child  was  reported  perfectly 
healthv. 


FOREIGN   BODIES  IN  THE  ESOPHAGUS.  335 

Remarks.  The  symptom  "cougliing  until  it  vomited"  was  quite  evi- 
dently due  to  the  leakage  of  the  milk  from  the  esophagus  into  the  trachea, 
where  the  cough  thus  excited  expelled  the  milk  from  the  mouth,  while 
the  portion  aspirated  produced  the  broncho-pneumonia.  Considering 
the  vague  history  of  missing  a  cuft  link,  and  the  age  of  the  child  (then 
only  six  weeks)  the  practitioner  is  to  be  complimented. 

The  prognosis  as  to  esophageal  function  after  cases  of  prolonged  so- 
journ of  foreign  bodies  is  closely  related  to  the  length  of  sojourn.  The 
longer  the  intruder  has  been  in  situ  the  greater  the  likelihood  of  stenosis. 
In  D.  Braden  Kyle's  unique  case  of  seventeen  years'  duration.  Fig.  21"), 
the  stenosis  required  after-treatment  which  Dr.  Kyle  carried  out  so  skill- 
fully as  to  get  an  excellent  ultimate  result.  Prognosis  may  be  made  very- 
grave  from  ill-ad\ised  interference,  especially  blind  bouginage  and  ex- 
ternal esophagotomy,  as  will  be  cited  under  treatment.  The  prognosis 
after  esophagoscopy  is  excellent  as  shown  by  the  statistics  given  in 
this  chapter. 


X 


Fk;.  206. — CufY  link  shown  in  Fig.  205. 

Even  if  the  foreign  body  becomes  dislodged  and  moves  downward 
the  patient  is  not  .safe.  It  may  cause  intestinal  perforation  (Fig.  207). 
So  long  as  the  inlrndcr  remains  in  the  body  the  prognosis  must  be 
guarded. 

Treatment.  If  t(ir  an\-  reason  immediate  removal  is  contraindi- 
cated,  bismuth  subnitrate  should  be  given  dry  on  the  tongue  in  small 
doses  fre(|uently  repeated.  It  will  adhere  to  denuded  surfaces.  Calomel 
may  be  advantageously  added  to  the  first  few  doses.  Removal  is  the 
only  treatment  to  be  seriously  considered.  With  tiie  relatively  high 
mortality  from  external  eso[)hagotomy,  it  certainly  seems  as  though  the 
operation  is  rarely  if  ever  justifiable  in  foreign  body  cases.  Compared 
to  other  operations  in  the  neck,  it  has  a  very  high  mortality.  Further- 
more, it  has  happened  more  than  once  that  an  external  esophagotomy 
done  on  the  strength  of  a  radiograph,  has  failed  to  find  the  foreign  body 
because  the  latter  has  passed  on  downward  into  the  thoracic  esophagus, 
where  it  cannot  be  reached  otherwise  than  esophagoscopically,  and  one 
such  case  has  been  recorded  in  which  the  patient  died  from  an  external 


336 


FOREIGN   BODIES  IN  THE  ESOPHAGUS. 


esophagotomy  at  which  the  foreign  body  was  not  found.  In  view  of 
these  things,  those  who  lia\e  had  most  experience  in  deaHng  with  the 
esophagus  regard  esophagotomy  as  unjustifiable  until  after  esophago- 
scopy  has  failed,  and  the  author's  personal  opinion  is  that  any  and  every 
foreign  body  that  has  gone  down  through  the  mouth  into  the  esophagus 
can  be  brought  back  the  same  way.  unless  it  has  already  perforated  the 


Fk;.  207. — Needle  in  the  intestine.  Deatli  resulted  fmm  septic  peritonitis  fol- 
lowing perforation.  Esophagoscopy  was  opposed  by  the  family  physician  when 
the  needle  was  in  the  esophagus.  The  position  of  the  stomach  is  shown  by  the 
bismuth  shadow.  Laparotomy  advised  when  needle  remained  in  one  place  in  in- 
testine for  6  days. 


esophageal  wall,  in  which  event  it  is  no  longer  a  case  of  a  foreign  body- 
in  the  esophagus.  Furthermore,  external  esophagotomy  recpiires  a  gen- 
eral anesthetic,  which,  because  of  its  relaxation  may  permit  the  foreign 
body  to  move  downward.  In  contrast  to  esophagotomy,  esophagoscopy 
does  not,  as  a  rule,  require  general  anesthesia,  and  while  it  iua\-  be  oc- 
casionally found  that  the  foreign  body  which  shows  so  plainly  in  the 
radiograph  has  moved  on  downward  to  a  lower  position,  or  even  into 
the  stomach  itself,  no  harm  has  been  done.     In  case  of  its  simply  having 


I'OKI-.IGN    liUUIES  IX  THE  ESOPHAGUS.  337 

moved  to  a  lower  position,  it  is  just  as  readily  removed  with  the  esoph- 
agoscope  as  if  it  were  at  the  higher  point  where  originally  seen  in  the 
radiograph.  The  most  favorahle  statistics  give  a  20  per  cent  mortality 
for  external  esophagotomy  in  adults.  The  mortality  is  still  higher  in 
children,  in  some  statistics  as  high  as  4'2  per  cent.  Comparing  such 
mortality  with  the  two  or  three  per  cent  mortality  in  esophagoscopy, 
the  operation  of  external  esophagotomy  for  foreign  bodies  has  been 
rightly  recommended  only  after  failure  of  esophagoscopic  extraction. 
Doubtless  blind  attempts  at  removal  have  increased  the  mortality  of 
both  procedures  but  as  it  has  probably  increased  them  both  in  the  same 
ratio  the  relative  percentages  still  hold  good.  It  must  be  borne  in  mind, 
also,  as  pointed  out  by  John  C.  DaCosta  (Bib.  IDl  )  the  esophagoscope 
in  the  hands  of  the  inexperienced  may  be  more  dangerous  than  external 
esojihagotomy.  A  recent  book  on  surgery  has  advised  the  passage  of  a 
i)ougie  to  determine  whether  the  foreign  body  is  present,  and  if  present 
to  push  it  down.  It  should  be  unnecessary  at  this  late  day  to  warn 
against  blind  bouginage  in  foreign  body  cases.  Citation  of  a  few  cases 
will  suffice.  <  )ne  death  from  j)erforation  with  the  bougie  which  did  not 
push  down  a  foreign  body  is  rejiorted  by  Arrowsmith.  The  patient  was 
moribund  on  admission  and  told  of  the  eftorts  of  a  physician  to  push  the 
foreign  body  down.  Mr.  Waggette  (Rib.  .5(i?  )  refers  to  a  case  in  which 
a  sharp  piece  of  bone  was  overriden  b\-  the  bougie  passed  by  competent 
surgeons.  If  the  bougie  will  thus  override  the  foreign  body  in  the 
hands  of  competent  surgeons,  and  in  certain  hands  may  cause  death,  its 
use  cannot  be  too  often  condemned  as  both  inefficient  and  dangerous. 
Emerson  (  I'.ib.  i:!!)  reports  the  fatal  case  of  perforation  of  the  esoph- 
agus and  aorta  by  a  chicken  iione  after  blind  bouginage  in  a  general 
hospital.  'I'he  author  can  cite  two  cases.  In  one  case,  seen  in  con- 
sultation, a  child  of  two  years  was  dying  from  acute  esophagitis.  A 
penny  had  lodged  in  the  esophagus  five  days  before.  Forceps  had  been 
passed  blindly,  without  an  esojihagoscope.  Two  days  after  this  utterly 
unjustifiable  procedure,  the  temperature  was  101°,  pulse  l-")0.  When 
the  author  saw  the  patient,  five  days  after  operation,  the  temperature 
was  subnormal,  jjulse  fluttering  and  uncountable,  sloughs  were  being 
vomited,  and  the  child  was  sinking  away  in  the  profotind  shock  of  a 
traumatic  esoi)hagitis.  The  author  concurred  in  wording  the  death  cer- 
tificate: "'Death  from  acute  esophagitis  following  the  swallowing  of  a 
])enny.''  It  was  really  due  to  the  absolute  ignorance  of  the  famil\-  i)hy- 
sician  who  had  never  iuard  of  esophagoscopy,  and  its  safety  in  trained 
hands.  In  another  case  a  child  of  six  years  was  admitted  to  the  Pres- 
byterian ilos]iil;il  with  the  lii^tory  that  live  days  before  she  had  choked 
and  Miniited  al  dinniT.     It  was  sup]>osetl  that  a  piece  of  bone  had  lodged 


338  FOREIGN   BODIKS  IK  TUB  ESOPHAGUS. 

in  her  throat.  Two  physicians  liad  worked  tor  two  hours  with  instru- 
ments on  the  anesthetized  patient,  but  had  failed  to  remove  any  foreign 
body.  The  child's  temperature  was  101°  F.,  pulse  128,  and  respiration 
28.  Appearance  septic,  breath  foul,  and  swallowing  difficult  and  very 
painful.  Inspection  of  the  pharynx  showed  a  putrid  gangrenous  mass 
of  mutilated  tissues,  too  severely  lacerated  to  justify  examination.  Dis- 
coloration and  swelling  externally  simulated  a  "Ludwig's  angina.''  Sep- 
tic symptoms  steadily  increased  and  the  child  died  five  days  after  ad- 
mission. Post  mortem  showed  an  abscess  in  left  hypopharynx,  gan- 
grenous esophagitis.  and  bodies  of  three  vertebrae  partially  denuded,  the 
lowest  damaged  being  the  sixth.  Macroscopically  and  microscopically, 
it  was  clear  that  the  condition  was  due  to  recent  trauma,  and  not  to 
tuberculosis  or  other  disease.  No  foreign  body  was  found.  This  case 
gave  a  typical  example  of  acute  esophagitis  from  blind  etiforts  at  removal 
of  ?.  foreign  body.  Whether  a  foreign  body  had  been  present  or  not  is 
not  the  point.  It  is  one  of  the  sad  duties  of  the  esophagoscopist  to  see 
little  children  brought  in  dying  or  seriously  ill  from  rough,  unjustifiable, 
brutal  attempts  to  remove  a  foreign  body  by  such  relics  of  obsolete  sur- 
gery as  the  Graefe  basket,  the  coin  catcher.  Bond's  forceps,  bristle  pro- 
bangs,  etc.  It  may  be  thought  that  the  bristle  probang  should  not  be 
included  here.  Possibly  its  use  may  not  be  very  dangerous  in  the 
adult,  but  in  infants  it  has  been  fatal.  The  author  has  in  his  collection 
of  esophagoscopically  removed  foreign  bodies  a  number  of  bristles  left 
behind  from  predecessor's  probangs.  Sir  Felix  Semon,  with  his  acute 
observation  and  analytical  mind,  pointed  out,  years  before  the  develop- 
ment of  esophagoscopy,  the  danger  of  attempting  to  push  down  a  foreign 
body  that  was  lodged  in  the  esophagus.  He  reported  cases  in  which  the 
foreign  body  had  escaped  such  efforts  and  others  in  which  the  foreign 
body  had  been  forced  to  perforate.  He  also  pointed  out  that  no  foreign 
body,  the  presence  of  which  has  been  actually  detected,  ought  to  be 
allowed  to  remain  impacted,  even  if  at  the  time  it  does  not  produce 
any  serious  symptoms.  These  two  principles  remain  to-day  fundamental 
in  dealing  with  foreign  bodies  impacted  in  the  air  and  food  passages. 
Yet  it  is  astonishing  how,  even  to-day,  practitioners  will  tell  patients  "to 
go  home  and  forget  about  it"  in  some  instances,  while  in  others  they 
will  produce  fatal  traumatism  by  usually  unsuccessful  blind  groping 
efforts.    Emetics  are  inefficient  and  dangerous. 

There  is  but  one  method  of  removal  worthy  of  serious  consideration 
and  that  is  by  esophagoscopy.  It  should  always  be  used  first.  If  it  fail, 
which  will  be  very  rarely,  then  external  operation  is  to  be  considered 
in  cervicallv  lodged  foreign  bodies. 


CHAPTER     XIX. 

Esophagoscopy  for  Foreign  Bodies. 

Mortality  and  results  of  esophagoscopy  for  foreign  bodies*  Of  193 
cases  of  esophagoscopy  for  foreign  body  by  various  operators,  the  in- 
truder was  removed  in  loo.  Of  the  38  not  removed,  26  went  down. 
There  were  \'i  deaths  (IM  per  cent).  It  is  interesting  to  note  that  of  the 
twe!\e  deaths  from  esophagoscopy  for  foreign  bodies,  eight  were  for 
bodies  in  the  upper  third,  four  of  the  patients  dying  during  operation,  and 
in  all  four  the  foreign  body  was  not  removed  until  after  death.  All  had 
been  given  chloroform,  though  this  was  probably  only  indirectly  the 
cause  of  death.  In  seven  of  the  eight,  the  eso])hagoscopy  was  done  by 
operators  whose  total  mimbcr  of  cases  was  less  than  three.  In  the  large 
clinics  (from  previously  published  statistics)  out  of  210  cases  of  foreign 
bodies  in  this  location,  all  were  removed  but  twelve,  and  these  went  down. 
The  mortality  in  the  large  clinics  was  3  per  cent.  It  is  also  interesting  to 
note  that  in  the  present  series  of  cases  there  were  two  deaths  from  lacer- 
ation of  the  esophagus  from  violent  removal  of  large  foreign  bodies,  an 
artificial  denture  in  one  case,  a  large  and  rough  bone  in  the  other.  In 
both  instances  the  operators  stated,  in  effect,  that  they  believed  they  could 
have  succeeded  in  devising  methods  of  safe  removal,  had  they  realized 
the  danger  of  esophageal  trauma.  Of  the  20(;  cases  of  esojihagoscopy  for 
foreign  bodies  in  the  hosj)itals  of  riltsburgh  and  in  tlie  autlim's  work  in 
other  cities  the  foreign  body  was  removed  in  ll'S,  and  escaped  downward 
in  eight.  There  were  four  deaths,  one  in  a  woman  of  ."ili  with  advanced 
iiei^n-itis;  the  other  llirre  deaths  were  in  ]iatients  admitted  with  severe 
laceration  of  the  esophagus,  from  i)revious  attempts  at  esophagoscopy. 
Four  other  cases  seen  in  extremis  are  not  included  because  owing  to 
f)roi()und  shock  no  esophagoscopy  was  doiic.  There  is  not,  and  there 
never  will  lie.  an  absolutely  safe  esopliagoscope  that  can  be  used  other- 
wise than  with  care  and  caution,   for  even  the  soft   stomach   tube  has 


•Abstracted,   with   additions,    from    tlie  autlioi's    Uniiport    >.u   the  IiUi'inatiunal 
Medicat  Congre.'^s,  T.onflon,  IHin. 


•340  USOPHAGOSCOPV  FOR   FOREIGN  EODIES. 

caused  perforation  and  death.  But  all  endoscopists  are  now  agreed  that 
skillfully  done  under  the  guidance  of  the  eye,  esophagoscopy  is  practically 
without  mortalitv,  if  considered  apart  from  the  trauma  incident  to  foreign 
bodies  and  their  extraction. 

Indications  for  esophagoscopy  in  suspected  foreign  body  cases. 
Esophagoscopy  is  indicated  in  every  case  in  which  a  foreign  body  is 
known  to  be  or  suspected  of  being  in  the  esophagus. 

Contraindications  to  esophagoscopy  in  foreign  body  cases.  There  is 
no  absolute  contraindication  to  esophagoscopy  for  the  removal  of  for- 
eign bodies  unless  the  patient  is  moribund  from  esophageal  trauma  from 
ill-advised  blind  efforts  at  removal ;  a  state  which,  while  less  common 
than  formerly,  is  still  not  unknown.  If  the  patient  is  in  bad  condition 
from  this  cause,  it  is  better  to  give  stimulants,  elevate  the  foot  of  the 
bed,  keei^i  the  patient  warm  with  blankets  and  liot  water  bottles  and  use 
all  other  means  to  counteract  the  shock  of  acute  traumatic  esophagitis 
before  removing  the  foreign  body.  liismuth  taken  dry  on  the  tongue  is 
the  best  local  treatment  in  these  cases.  If  there  is  a  serious  state  of 
water  hunger  from  occlusion  of  the  esophagus  by  a  foreign  body  the 
esophagoscopy  should  be  postponed  until  some  water  can  be  gotten  into 
the  circulation.  Water-starved  patients  make  bad  subjects  for  any  pro- 
cedure and  as  the  state  is  not  fully  understood  the  following  case  may  be 
cited  in  the  words  of  the  pediatrist,  H.  T.  Price,  who  was  associated  with 
the  author  in  the  case  of  cherry  stone  occluding  the  previously  strictured 
esopha.gus  of  a  girl  of  five  years.  No  food  or  water  had  been  swallowed 
for  five  days. 

Report  bv  Dr.  I'rice.  "Condition  was  alarming.  Child  unable  to  sit 
up  when  placed  in  a  chair,  eyes  sunken  and  staring,  color  very  sallow 
(yellowish  ),  skin  dry  and  harsh,  lips  very  pale,  child  spoke  with  difficulty, 
seemed  bewildered.  Pulse  almost  imperceptible,  no  further  examination 
made.  Ordered  normal  saline  solution  by  hypodermoclysis  and  str\ch- 
nine  sulphate  hypodermically.  Seen  about  an  hour  later :  condition  some- 
what better,  pulse  had  better  volume  but  was  rapid.  One  pint  normal 
saline  given  by  high  enema,  all  retained  and  child  removed  to  operating 
room.  During  examination  child's  condition  continued  to  improve  and 
no  water  expelled  in  spite  of  straming.  Immediately  after  removal  of 
cherry  stone,  while  on  the  table  child  swallowed  water  which  passed  read- 
ily into  stomach  and  condition  steadily  impro\ed.  Child  seemed  'out  of 
danger'  from  water  hunger  about  eight  injurs  after  admission." 

Aneurysm,  serious  cardiac  and  vascular  diseases,  high  blood  pres- 
sure, history  of  apoi)]exy  and  tlic  like  are  not  contraindications  for  the 
cautious  esophagoscopic  removal  of  foreign  bodies,  but  thev  render 
esophagoscopy  for  any  other  jturpose  inadvisaljle.    In  a  foreign  body  case 


ESOPHAGOSCOPY  FOR   FORKIGN   BODIKS.  341 

if  there  is  surgical  emphysema,  irritability,  increasing  fever,  increasing 
rapidity  of  respiration,  severe  pain  in  the  chest,  aching  in  character,  the 
foreign  body  has  probably  perforated  and  esophagoscopy  is  of  question- 
able advisability,  though  in  one  such  case  the  foreign  body  had  not  yet 
escaped  and  was  caught  and  removed  by  the  author.  The  above  men- 
tioned symptoms  may  be  due  to  pleural  perforation,  in  which  case  pneu- 
mothorax can  be  diagnosticated  by  physical  signs  and  by  radiography. 
Endoscopic  appearances  of  forci(jn  bodies  in  the  esophagus  are  the 
same  as  those  previously  mentioned  in  connection  with  foreign  bodies  in 
the  air  passages  e.xcept  that  the  color  and  form  of  esophageally  lodged 
foreign  bodies  may  be  modified  by  accumulation  of  food  debris  or  by 
bismuth  given  for  radiographic  or  therapeutic  purjioses.  Quite  fre- 
quently the  first  view  of  a  foreign  substance  will  be  a  whitish  or  grayish 
mass  of  food  debris  mixed  with  secretions.  The  reader  is  referred  to  the 
comments  on  the  difficulties  due  to  the  color  of  a  foreign  body  in  the 
hrimclius  which  ajiply  with  etjual  force  to  intruders  in  the  esophagus. 
Kahier  rejjorts  a  case  in  which  a  nodulation  due  to  the  calcification  im- 
pressions of  the  thyroid  gland  were  mistaken  for  a  foreign  body  in  the 
eso])hagus. 

ESOPHAGOSCOPIC   EXTR.VCTION    OF   FOKKIGX    BODIES. 

Anesthesia,  preparation  of  the  patient,  position  of  the  patient,  tech- 
nic  of  introduction  of  the  esophagoscope  and  of  the  esopliagcal  speculum 
have  all  been  considered  in  prior  chapters.  The  "Rules"  mentioned  under 
bronchoscoi)y  for  foreign  bodies  are  applicable  to  esophagoscopy  for  the 
same  class  of  cases.  As  there  mentioned  it  is  unwise  to  go  into  any  for- 
eign body  case  insufficiently  equipped  with  the  idea  of  taking  a  prelim- 
inary look.  Everything  likely  to  be  needed  for  the  extraction  of  the  in- 
truder in  question  should  be  sterile  and  ready  for  immediate  use.  A 
second  trial  may  find  the  problem  incomparably  more  difficult.  There 
should  also  lie  ready,  in  every  eso])hageal  case,  a  direct  laryngoscojie  and 
a  bronchoscope,  for  adult  or  child  as  the  case  may  lie.  The  foreign  body 
may  i)e  in  the  air  passages,  eitlier  ])rimarily  or  by  erosion  as  in  the  case 
[jreviously  cited:  or,  more  important  still,  respiratory  arrest  may  result 
from  overriding  or  displacement  of  the  intruder  liv  the  esophagoscope  or 
by  cfli'orts  at  disimpaction,  faulty  position  of  the  patient,  etc.  In  such 
cases  iirompt  insertion  of  a  bronchoscope  and  i)ronchosco])ic  oxygen  in- 
sufflation may  save  life  wilhmit  a  tracheotomy.  Tracheotomy  instruments 
should  always  be  upon  the  sterile  instrument  table  as  a  matter  of  routine. 
'J'hose  who  are  prompt  and  skillful  in  bronchoscopy  will  not  need  them 
ruid,  indeed,  it  is  exceedingly  rarely  that  resjiiratory  arrest  occurs  in 
esophagoscopy,  especially  if  no  anesthesia  is  used :  yet  it  is  a  good  general 


342  ESOPHAGOSCOPY  FOR  FOREIGN  BODIES. 

rule  in  all  traclieo-esophageal  cases  to  have  tracheotomy  instruments  al- 
ways prepared  as  a  routine  procedure  for  the  rare  cases  of  urgent  ne- 
cessity. 

The  author  has  among  his  personal  armamentarium,  two  lengths  of 
esophagoscopes,  one  for  children  and  one  for  adults.  It  is  impossible,  in 
looking  through  the  tube  to  tell  whether  a  short  or  the  long  tube  is  being 
used,  and  so  far  as  instrumentation  is  concerned,  there  is  no  advantage 
in  short  instruments,  provided  the  long  ones  are  properly  constructed. 
The  little  light  is  close  to  the  foreign  body  and  perfectly  illuminates  the 
field,  no  matter  how  many  instruments  are  introduced  in  the  tube.  All 
that  is  necessary  is  to  look  past  the  instruments.  The  instrument  does 
not  lessen  the  illumination.  In  using  the  long  tube,  if  the  foreign  body 
is  not  found  at  the  level  where  it  shows  in  the  radiograph,  the  entire 
esophagus  is  at  once  explored  clear  through  to  the  stomach,  and  even  the 
cardial  end  of  the  stomach  can  be  searched.  So  far  as  introduction  is 
concerned,  a  long  tube  is  easier  of  manipulation  than  a  short  tube.  A 
tube  of  large  diameter  is  always  preferable,  because  with  it  one  is  much 
less  likely  to  override  the  foreign  body ;  but  on  the  other  hand,  a  tube  of 
large  diameter  is  much  less  easy  of  introduction.  For  complicated  re- 
movals, such  as  the  closing  of  safety  pins,  the  cutting  of  fishhooks  and 
the  like,  of  course  the  manipulations  are  much  easier  through  a  tube  of 
large  diameter.  These  considerations,  however,  must  not  lead  us  to  en- 
danger our  patient  by  the  use  of  too  large  a  tube.  The  author  uses  a 
tube  of  7  mm.  internal  diameter  in  children  and  10  mm.  diameter  in 
adults.  In  no  case  is  it  wise  to  use  a  mandrin  in  exploring  the  esophagus 
for  foreign  bodies.  A  mandrin  makes  introduction  somewhat  easier  for 
the  beginner,  but  it  is  very  likely  to  cause  the  overriding  of  a  foreign  body 
in  the  cer\-ical  esophagus,  and  there  is  always  risk  of  a  diseased  esophageal 
wall  w  hether  a  foreign  body  be  present  or  not. 

Sponging  with  the  long  sponge  holder  should  be  done  very  care- 
fullv.  lest  the  foreign  body  be  hidden  in  the  secretions  and  lie  dislodged 
by  the  sponging.  It  is  usually  unnecessary  to  sponge  at  this  stage  be- 
cause the  aspirator  in  the  wall  of  the  esophagoscope  is  draining  away  the 
secretions.  If  small  food  masses  are  seen,  it  is  almost  certain  that  the 
foreign  body  lies  just  below,  and  these  food  masses  should  not  be  wiped 
away  but  should  be  picked  out  with  the  forceps  lest  the  foreign  body  be 
disturbed.  When  the  tube  mouth  reaches  the  proximity  of  the  foreign 
body,  it  will  be  noticed  if  the  foreign  body  is  of  sufficient  size  to  distend 
the  esophagus,  that  the  esophagus  seems  to  roll  in  over  the  foreign  body 
which  only  shows  in  the  center  of  the  rather  small  lumen  of  the  esoph- 
agus. As  the  tube  mouth  approaches  more  closely,  this  folding  in  of 
the  mucosa  will  be  distended  and  the  foreign  body  comes  more  largely 


ESOPIIAGOSCOPY  FOR  FOREIGN  BODIES.  343 

into  view.  If  the  foreign  body  is  a  coin  or  something  of  that  nature,  not 
involving  any  special  problem  on  removal,  it  is  best  not  to  approach  too 
closely  with  the  tube  month:  but  to  insert  the  forceps  just  as  soon  as  the 
foreign  body  comes  into  view.  The  forceps  jaws  should  always  open  in 
the  up  and  down  direction,  regardless  of  the  plane  in  which  the  foreign 
body  is  to  be  seen.  With  all  flat  objects,  this  will  bring  the  forceps  in  the 
correct  iiosition.  In  case  of  foreign  bodies  situated  in  other  planes,  or  to 
be  seized  in  other  planes,  it  is  better  not  to  rotate  the  stilette  of  the  for- 
ceps to  make  the  jaws  open  in  an\  cither  plane;  but  rather  to  place  the 
handle  in  the  position  required  for  the  jaws  to  open  in  the  proper  direc- 
tion. The  advantage  of  this  is  that  the  jaws  always  open  in  the  same 
way,  making  it  very  much  easier  to  follow  their  movements  by  sight. 
Special  problems  of  removal  will  be  considered  later. 

Difficulties.  The  difficulties  of  introduction  of  the  esophagoscope 
have  been  previously  considered.  The  difficulties  of  removal  will  be 
considered  as  mechanical  problems.  But  a  few  words  must  be  said  of 
ditficulties  in  finding  a  foreign  body  known  to  be  present. 

"Overriding,"  or  failure  to  find  a  foreign  body  knoivn  to  be  present. 
One  of  the  most  difficult  things  for  the  beginner  in  esophagoscopy  to  un- 
derstand is  how  a  foreign  body,  especially  one  not  of  minute  size,  can 
"get  lost"  in  the  esophagus.  The  author  is  often  asked  how  it  is  possible 
for  an  esophagoscope  to  be  passed  many  times  into  the  esophagus,  and 
not  reveal  a  penny,  for  instance,  which  a  radiograph  shows  to  be  present. 
The  explanation  is  found  in  the  anatomy  of  the  eso])hagus.  If  the 
esophagus  were  a  tube  of  equal  size  throughout  with  rigid  walls  standing 
patulous  without  folds,  or  if  an  esoph;igoscope  large  enough  entirely 
to  fill  the  lumen  were  passed,  the  foreign  body  would  promptly  present 
itself  at  the  lube  mouth.  But,  as  shown  in  Fig.  145,  the  esophagus  is 
constricteil  at  certain  points  which  prevents  the  passage  of  an  esoph- 
agoscope large  enough  to  lill  out  its  collapsed  walls  at  the  larger  portions 
in  which  small  foreign  bodies  such  as  needles,  pins,  and  fish  ribs  may 
be  hidden.  P-ut  this  is  not  often  the  explanation  of  failure  to  find 
coins.  More  often  coins  and  similar  (jbjecls  are  just  below  the  plica 
cricopharyngeus  which  latter  makes  a  veritable  chute  in  throwing  the 
end  of  the  esophagoscope  forward  to  override  the  foreign  body  and 
to  interpose  a  layer  of  tissue  between  the  tube  and  the  coin  so  that  con- 
tact at  the  side  of  the  tube  after  the  tube  mouth  is  passed  is  not  felt. 
Another  hiding  place  for  foreign  bodies,  esi)ecially  those  of  small  size,  is 
tlie  pyriform  sinuses.  Food  naturally  passes  through  both  pyriform 
sinuses  and  there  is  so  little  room  directly  back  of  the  cricoid  that  the 
esophagoscojie  is  usually  passed  through  one  of  the  two  sinuses,  general- 
ly the  right.     Therefore  if  a  foreign  bodv  is  not  found  on  the  passage 


344  ESOPHAGOSCOPY  FOR  FOREIGN  BODIES. 

downward,  the  distal  end  of  the  tube  should  be  kept  pressing  to  the  left 
on  withdrawal  so  as  to  explore  the  left  sinus  on  the  wav  out.  Of  course 
if  the  radiograph  should  show  the  intruder  to  be  in  the  left  pyriform  sinus 
the  esophagoscope  may  be  passed  that  way  though  the  retrograde  search 
has  the  advantage  of  not  risking  the  pushing  of  the  intruder  downward. 
A  better  method,  however,  in  all  cases  of  high  foreign  bodies  is  to  use 
the  esophageal  speculum,  Fig.  21.  This  instrument  has  enabled  the 
author  to  remove,  in  three  instances,  the  particularly  elusive  rib  bones  of 
fish  after  skilful  esophagoscopists  had  failed.  In  one  instance  two  good 
tube  workers  had  each  tried  for  two  hours  under  general  anesthesia  to 
remove  a  tish  rib  which  was  promptly  revealed,  not  by  superior  skill  on 
the  author's  part,  but  by  the  advantage  yielded  by  the  use  of  the  eso- 
phageal speculum.  The  bone  was  sticking  deeply  in  the  esophageal  wall 
just  below  the  plica  cricopharyngeus.  Coins  that  have  been  in  the  esoph- 
agus a  few  weeks  show  a  polished  streak  up  and  down  the  middle  third 
of  their  anterior  (rarely  posterior)  surface  evidently  corresponding  to 
the  usual  course  of  food  in  swallowing,  the  esophagus  not  being  fully 
dilated,  and  the  lateral  edges  of  the  coin  being  clamped  in  the  lateral  folds 
of  the  esophageal  wall.  In  some  instances  the  esophagoscope  overridmg 
the  tube,  probably  follows  the  same  route  (anterior  to  the  coin  intruder). 
When  a  silver  coin  has  been  in  the  hypopharynx  the  central  third  is 
darkened  by  sulphides,  while  the  lateral  thirds,  corresponding  to  the 
pyriform  sinuses  are  bright  from  passage  of  the  food  at  the  sides  of 
the  upper  part  of  the  hypopharynx.  The  intruder  may  be  overridden  be- 
cause it  is  hidden  by  secretions,  or  by  being  buried  under  the  mucosa  or 
under  inflammatory  tissue.  These  are  unusual  and  in  most  instances  the 
trouble  will  be  found  to  be  the  chute-like  eiifect  of  the  cricopharyngeus 
or  the  lurking  of  the  foreign  body  in  the  other  pyriform  sinus  or  in  the 
undilated  folds  of  the  esophagus,  to  all  of  which  the  use  of  an  esophagos- 
cope of  relatively  small  diameter  contributes.  Summarizing,  the  chief 
factors  in  overriding  of  an  esophageally  lodged  foreign  body  are: 
J.     The  chute-like  effect  of  the  plica  cricopharyngeus. 

2.  The  lurking  of  the  foreign  body  in  the  unexplored  pyriform 
sinus. 

3.  The  use  of  an  esophagoscope  of  small  diameter. 

4.  The  obscuration  of  the  intruder  by  secretion  or  food  debris. 

■>.  The  obscuration  of  the  intruder  by  its  penetration  of  the  eso- 
phageal wall. 

6.     The  obscuration  of  the  intruder  by  inflammatory  sequelae. 

Extraction  of  foreign  bodies  icith  the  esophageal  speculum.  Almost 
all  of  the  esophageally  lodged  foreign  bodies  are  to  be  found  at  or  above 
the  sternal  notch.    Of  these,  fully  one-half  can  be  removed  with  the  eso- 


ESOPIIAGOSCOPV  FOR  FORKIGN   BODIES.  345 

pliageal  speculum.  It  nuust  be  remembered,  however,  that,  in  a  radio- 
graph, a  foreign  body  may  look  much  higher  than  it  really  is.  Doubt- 
less this  is  the  reason  why  so  many  deplorable,  even  fatal,  attempts  at 
blind  removal  with  forceps  are  made.  It  seems  an  easy  task  to  reach  it 
with  almost  any  kind  of  forceps — even  a  hemostat.  When  an  esophago- 
scope  is  passed,  the  reverse  mistake  is  usually  made.  The  foreign  body 
is  reached,  possibly  overridden  without  being  seen,  before  the  operator 
realizes  that  he  is  down  to  the  level  indicated  in  the  radiograph.  A  cor- 
rect estimate  is  made  more  dii'licult  by  the  distortion  dependent  upon  the 
position  of  the  radiographic  tul)e.  If  the  tube  be  placed  exactly  over 
the  foreign  body,  that  is,  if  the  intruder  and  the  center  of  the  radio- 
graphic tube  are  on  the  same  vertical  line,  there  will  be  no  distortion. 
But  as  this  cannot  be  done  without  knowing  beforehand  the  location  of 
the  intruder  it  would  require  a  repetition  of  the  radiography.  For  prac- 
tical purposes  it  may  be  said  that  any  foreign  body  that  is  not  more  than 
one  centimeter  below  the  lower  border  of  the  cricoid  cartilage  in  a  child, 
or  more  than  two  in  an  adult,  is  more  easily  dealt  with  by  the  esophageal 
speculum  than  by  the  esophagoscope  provided  the  esophagoscopist  has 
mastered  the  use  of  the  speculum.  lUit  all  cases  can  be  dealt  with  by 
the  long  esophagoscopic  tube,  and  thorough  mastery  of  it  will  be  more 
successful  than  partial  mastery  of  each.  In  infants  the  child's  size  laryn- 
goscope may  be  used  as  an  esophageal  speculum. 

The  introduction  of  the  esophageal  speculum  is  described  in  a  pre- 
vious chapter.  Certain  points  should,  however,  be  emphasized.  The  au- 
thor prefers  recumbency  of  the  patient.  The  head  of  the  patient  must  be 
elevated  above  the  level  of  the  table  and  should  be  extended  fully  but  not 
violently.  The  speculum  is  held  in  the  operator's  left  hand  as  shown  for 
the  laryngeal  s])eculum  in  Figs.  H!i  and  IMi.  The  tip  of  the  instrument. 
which  should  be  very  smooth,  is  slid  intfi  the  right  [>yriform  siiuis  along 
the  posterior  hy[)opliar\-ngeal  wall  with  only  enough  anterior  lifting  with 
the  tip  to  o])en  up  llu-  lunien  ahead.  No  amount  of  lifting  can  pull  the 
cricoid  cartilage  away  from  the  spine,  and  all  the  displacement  required 
is  to  lift  the  walls  of  the  right  pyriform  sinus.  This  at  times  requires 
what  to  some  may  seem  a  considerable  degree  of  power,  but  it  is  in  no 
case  as  nnich  as  reiiuired  for  a  goofl  ex]iosure  of  the  larynx  by  direct 
laryngoscopy  by  the  dorsolingual  route.  When  the  bottom  of  the  pyri- 
form sinus  is  reached,  it  will  be  known  by  the  obstruction  due  to  the 
cricoiiharyngeal  fold  coming  forward  from  the  posterior  (lower  in  the 
recumbent  patient )  wall  and  seeming  to  cause  the  lumen  entirely  to  dis- 
appear. .\t  this  stage  tlu'  lip  of  the  speculum  should  be  guided  slight- 
ly tow.ird  the  median  line  and  lifted.  Too  powerful  lifting  here  again 
is  to  lie  ;i\oided  because  the  cricophan,'ngeal  fold  will  follow  all  the 
more.      It   is   better   to   jiusli    the   speculum,    not   too   forcibly,    with    the 


346  ESOPHAGOSCOPY  FOR  FOREIGN  BODIES. 

thumb  and  finger  of  the  right  hand  while  the  left  hand  exerts  sufficient 
lifting  motion  to  find  the  lumen.  Just  at  this  point,  it  is  especially  ne- 
cessary to  proceed  cautiously  as  the  foreign  body  very  often  lies  im- 
mediately- below  the  spasmodically  contracted  plica  cricopharyngeus. 
If  this  spasm  suddenly  relaxes,  the  foreign  body  may  be  pushed  down- 
ward by  a  sudden  advance  of  the  speculum.  The  head  of  the  patient 
at  this  stage  must  be  noted  to  see  that  it  is  high.  If  not,  it  must  be 
raised  for  the  reasons  explained  in  the  schema.  Fig.  149.  As  soon  as 
the  tip  of  the  speculum  passes  the  plica  cricopharj-ngeus  this  fold  will 
obscure  the  view  of  half  the  lumen.  The  plica  should  be  pushed  pos- 
teriorly with  the  closed  alligator  forceps  (of  Mosher  or  Paterson) 
used  simply  as  a  repressor,  as  the  tube  advances  (Plate  III,  Fig.  3). 
As  soon  as  the  foreign  body  is  seen,  if  it  be  a  coin,  smooth  button,  or  the 
like,  it  may  be  at  once  seized  with  the  alligator  forceps.  If  it  be  a 
sharp,  rough,  irregular  or  transfixed  body  it  must  be  seized  according 
to  the  mechanical  problem  presented.  In  case  of  such  bodies,  instead 
of  the  plain  alligator  forceps  the  author's  alligator  rotation  forceps 
(Fig.  210)  should  be  used  (closed)  for  the  retraction  of  the  plica  crico- 
pharyngeus so  as  to  be  ready  to  seize  the  foreign  body  in  such  a  way  as 
to  permit  of  the  rotation  of  the  intruder  as  explained  under  "Mechanical 
Problems." 

.Mechanical  problems  of  esopliagoscopic  removal  of  foreign  bodies. 
If  an}-  argument  were  needed  against  the  blind  attempts  at  removal,  it 
is  the  consideration  of  the  various  admirable  solutions  of  mechanical 
problems  that  have  been  devised  for  endoscopic  use.  To  any  one  who 
will  review  this  subject,  the  use  of  blind  methods  is  preposterous,  almost 
criminal.  The  esophagus  is,  surgically,  the  most  intolerant  organ  in 
the  body.  It  must  be  dealt  with  in  the  most  careful,  gentle  w-ay,  always 
under  the  guidance  of  the  eye.  The  greatest  triumph  of  esophagoscopy 
over  every  other  method  of  dealing  with  foreign  bodies  in  the  esoph- 
agus is  in  the  low  mortality  of  esopliagoscopic  methods.  The  thought 
that  if  left,  the  body  jirobably  will  be  fatal  anyway,  does  not  justify  vio- 
lence. A  careful  study  of  the  mechanical  problems  presented  will  al- 
ways discover  a  safe  method  of  removal.  In  view  of  this,  the  great 
temptation  to  remove  the  body  at  all  hazards  once  it  is  grasped,  must 
be  resisted.  Most  of  the  mechanical  problems  and  their  solution  as 
considered  in  connection  with  bronchoscopy  for  foreign  bodies,  are 
equally  ajiplicable  to  esophagoscopy. 

As  in  bronchoscopy  side  movements  of  the  forceps  are  accomplished 
by  the  leverage  of  the  endoscopic  tube,  the  mouth  of  which  can  be  used 
to  force  the  distal  end  of  the  forceps  in  any  direction  angular  to  the 
long  axis  of  the  esophagus. 


I 


ESOPHAGOSCOPY  FOR  FOREIGN  BODIES. 


347 


Extraction  of  foreign  bodies  fixed  crosswise  in  the  esophagus. 
Bodies  fixed  crosswise  in  the  esophagus  present  much  the  same  problem 
and  are  removable  upon  the  same  principle  as  those  fixed  crosswise  in 
the  bronchi,  to  which  section  the  reader  is  referred.  There  are,  how- 
ever, some  problems  of  crosswise  fixation  that  are  peculiar  to  esophagos- 
copy.  For  instance,  in  the  esophagus  there  is  no  limit  to  distance  to 
which  a  long  foreign  body  may  be  pushed  downward  to  disengage  the 
point.  In  the  bronchi,  however,  a  long  foreign  body  may  already 
have  one  end  down  as  far  as  it  can  go,  so  that  disengaging  the 
buried  upward-projecting  point  by  pushing  the  foreign  body  downward 
becomes  a   difficult   matter.      One   of   the  most   important   things  in   the 


Fig.  208.— The  problem  of  the  horizontally  transfixed  foreign  body  in  the 
esopha.i.'US.  The  point,  D,  had  causlU  as  the  bone,  A,  was  being  swallowed.  The 
end,  E,  was  forced  down  to  C,  by  food  or  by  blind  attempts  at  pushing  the  bone 
downward.  The  wall,  F,  should  be  pushed  laterally  out  to  J,  permitting  the  forceps 
to  grasp  the  end,  M,  of  the  bone.  Traction  in  the  direction  of  the  dart  will  dis- 
impact  the  bone  and  permit  it  to  rotate.  The  author's  rotation  forceps  are  used 
as  at  K. 


removal  of  a  foreign  liody  from  either  the  esophagus  or  the  tracheo- 
bronchial tree  is  to  determine  at  what  point  the  foreign  body  should  be 
seized  in  order  that  it  shall  come  out  without  injury  to  the  tissues. 
Therefore,  in  all  cases  except  those  of  smooth  disk-like  bodies,  it  wcnild 
be  a  serious  error  not  to  get  a  good  view  of  the  foreign  body  before  at- 
tempting to  seize  it  with  the  forceps.  In  case  of  thin,  sharp  foreign 
bodies,  such  as  bones,  needles,  double  pointed  tacks,  pins,  dentures, 
safety  pins,  an<l  the  like,  found,  as  they  often  are,  crosswise  in  the  esoph- 
agus, very  careful  work  is  necessary  (Fig.  208).  Foreign  bodies  reach 
this  ])osition  i)n)bably  by  one  point,  for  instance,  D,  sticking  in  the 
esophageal   wall.       The   foreign   bmly    is   then   in    the   jiosition  shown   at 


348 


ESOPIIAGOSCOPY  FOR  FOREIGN  BODIES. 


A,  by  the  dotted  line.  The  force  of  the  subsequently  swallowed  food 
continually  pushes  the  upper  point,  E,  downward  until  it  reaches  the 
maximum  stretch  of  the  esophagus,  as  shown  at  B.  To  remove  such 
a  body,  it  is  necessary  to  catch  one  of  the  ends,  either  D  or  C,  never 
by  the  middle,  B,  as  traumatism  would  be  almost  certain  to  follow  the 
latter  procedure.  If  either  end  of  the  intruder  is  higher,  this  is  the 
end  to  seize.  When  the  intruder  is  first  seen  it  is  usually  the  central 
part,  B,  that  is  in  front  of  the  tube  mouth.  In  order  to  apply  the  for- 
ceps at  the  end,  M,  it  is  necessary  to  move  the  esophageal  wall,  F,  out 
to  the  position  shown  by  the  dotted  line,  J,  by  swinging  the  esophago- 
scope  as  a  lever,  the  proximal  end  of  which  moves  in  a  direction  oppo- 


FiG.  2og. — Solution  of  the  mechanical  prolilem  of  the  button  or  other  disk- 
like object  with  a  sharp  point.  If  withdrawn  with  a  plain  forceps  applied  as  at 
A,  the  point,  B,  will  rip  open  the  esophageal  wall.  If  grasped  at  C,  the  point,  D, 
will  rotate  in  the  direction  of  F  and  will  trail  harmlessly  behind.  To  permit 
rotation,  the  author's  rotation   forceps  are  used  as  at  H. 


site  to  that  desired  for  the  lower  end.  Pins  lodged  in  the  esophagus, 
are,  in  the  author's  experience,  almost  invariably  found  point  down- 
ward, exactly  opposite  to  their  position  in  the  trachea  and  bronchi.  The 
probable  reason  for  this  is  that  in  the  air  passages  gravity  acting  strong- 
est in  the  head  of  the  pin  causes  it  to  fall  head  lowermost.  In  the 
esophagus,  which  is  a  collapsed  canal,  there  is  less  chance  for  gravity  to 
act  effectively,  and,  more  important,  pins  going  head  first  probably  do 
not  lodge,  hence,  pass  on  through;  whereas,  if  they  start  point  first,  the 
point  will  stick  into  the  lateral  wall.  It  is  the  lodged  cases  that  come 
to  the  esophagoscopist.  The  importance  of  this  as  a  mechanical  prob- 
lem lies  in  the  necessity  for  caution  in  the  esophagoscopy  lest  the  head 


ESOPIIAGOSCOPY  FOK  FOREIGN  BODIES.  349 

of  the  pin.  impinging  on  the  esophagoscope,  may  cause  the  point  to  per- 
forate, either  by  the  direct  push  of  the  esophagoscope  against  the  pin 
or  the  counterpush  of  the  heaving  uijward  of  the  esophagus  in  reflex 
mo\ements  of  vomiturition  or  vomiting. 

Extraction  of  broad  foreign  bodies  Inning  a  sharp  point.  As  illus- 
trateti  in  Fig.  2o!».  if  the  forceps  were  used  to  grasp  the  foreign  body 
flatly  by  tlie  portion  which  preseiUed,  as  shown  schematically  at  A,  Fig. 
2(i'.i,  the  point,  B,  would  ri])  tlie  esophagus  open.  If,  on  the  other  hand, 
tlie  button  were  caught  with  forceps  which  touched  onlv  at  the  points 
and  these  jminis  were  applied  to  one  side,  as  shown  at  C,  as  soon  as  the 
traction  was  made,  the  point.  D,  would  rotate  to  the  position  shown  by 
the  dotted  line.  F  G,  and  would  lie  withdrawn  harmlessly.  Free  rota- 
tion is  permitted  by  the  forceps  which  touch  the  foreign  body  only  at 
the  point,  as  shown  at  H.     The  forceps  used  for  this  purpose  are  the  au- 


■30  cm 


Fig.  210. — Author's  rotation  forceps  (short  form)  for  permitting  foreign 
bodies  to  rotate  to  the  jiosition  of  least  harm  and  least  resistance.  For  use 
through  the  esophageal  speculum. 

thor's  rotation  force])s  shown  in  Fig.  33.  For  use  with  the  esophageal 
speculum,  the  author's  alligator  form  of  rotation  forceps,  Fig.  210,  are 
more  convenient.  These  forceps  are  dangerous  to  use  otherwise  than 
by  sight,  because  of  the  possibility  of  trauma. 

Extraction  of  open  safety  pins  from  the  esophagus.  II  lodged  point 
downward  it  is  necessary  only  to  pwW  the  pin  into  the  esophagoscope  to 
close  it,  but  in  so  doing  the  hook-like  protector  end  of  the  i)in  may  cause 
trauma.  It  is  better  to  hold  the  near  end  of  the  pin  with  the  forceps 
while  the  esophagoscope  is  pu.shed  down  over  the  pin.  .\n  open  safety 
pin  lodged  point  upward  in  the  esophagus  presents  certain  peculiar  ele- 
ments of  danger,  and  peculiar  difficulties  of  removal.  When  the  esoph- 
agoscopist  sees  the  [lin  in  the  esophagoscope,  the  temjitation  to  seize 
it  and  remove  it  is  great.  To  do  so  is  almost  certain  death.  Besides  the 
risk  of  septic  mediastinitis  and  iileiiritis.  there  is  the  immediate  surgical 


3.50 


ESOPHAGOSCOPY  FOR  FOREIGN  BODIES. 


risk.  Two  such  cases  have  come  to  the  writer's  knowledge  by  com- 
munications. In  one  instance,  death  was  from  hemorrhage  into  the 
mediastinum.  What  vessel  was  perforated  was  not  known.  From  the 
location  of  the  pin,  it  was  probably  the  aorta.  In  the  other  instance, 
shock  from  esophageal  trauma  was  the  cause.  In  adults  or  older  chil- 
dren, the  pin  can  be  closed  before  removal  as  described  in  connection 


Fig.  211. — Radiograph  by  Dr.  George  C.  Johnston,  showing  open  safety  pin, 
point  up,  in  the  esophagus  of  an  infant,  aged  eleven  months.  Pin  was  passed  into 
stomach,  turned  and  removed  esophagoscopically.  Pin  retouched  for  clearness. 
(Author's  case). 


with  safety  pins  in  the  bronchi.  The  author  has  had  a  number  of  such 
cases.  In  infants,  the  esophagus  is  already  in  such  a  state  of  tension  by 
the  stretching  spread  of  the  spring  (E,  Fig.  212),  that  perforation  is  cer- 
tain if  the  dilatation  of  the  insertion  of  an  instrument  be  added.  The 
solution  of  the  mechanical  problem  of  safe  removal  when  the  first  under- 
noted  case  presented  itself,  led  the  author  to  devise  a  new  method  which 


ESOPHAGOSCOPV  FOR  FOREIGN  BODIES. 


351 


is  practicable  for  anyone  who  has  practiced  gastroscopy.  Republication 
here  of  a  report  (Bib.  25(i)  of  the  first  two  cases  will  suffice  to  illustrate 
the  method. 

Elizabeth  G.,  aged  eleven  months,  referred  by  Dr.  August  Soffel 
and  Dr.  C.  C.  Sandels.  .Admitted  to  the  Eye  and  Ear  Hospital  August 
13,  1909,  with  a  history  of  having  swallowed  a  safety  pin.  .\  radio- 
graph (Fig.  211),  by  Dr.  Oeorge  C.  Johnston,  showed  the  pin  to  be  of 
large  size  and  spread  so  widely  open  that  it  seemed  certain,  considering 


Fin.  212. — Schema  showing  the  author's  method  of  removal  of  upward  pointed 
esophageally  lodged  open  safety  pins  by  passing  them  into  stomach,  where 
they  are  turned  and  removed.  The  first  illustration  (A)  shows  the  rotation  for- 
ceps before  seizing  pin  by  tlie  ring  of  the  spring  end.  (Forceps  jaws  are  shown 
opening  in  the  wrong  diameter).  At  B  is  shown  the  pin  seized  in  the  ring  by  the 
points  of  the  forceps.  At  C  is  shown  the  pin  carried  into  the  stomach  and  about 
to  be  rotated  by  withdrawal.  D,  the  withdrawal  of  the  pin  into  the  esophagoscope 
which  will  thereby  close  it.  If  withdrawn  by  flat-jawed  forceps  as  at  F,  the  eso- 
ph:igc;d  wall  would  be  fatally  lacerated. 


the  age  of  the  patient,  that  the  esophagus  was  perforated.  The  tem- 
perature lli'i.l,  the  res])iration  10,  the  jmlsc  1  10,  weak  and  irritable,  all 
plainly  indicated  aiute  esophagitis.  To  use  the  safety  pin  closer,  which, 
because  of  the  small  esojihagus,  would  have  to  be  passed  external  to  the 
tube,  before  the  insertion  of  the  tube,  was  not  to  be  thought  of  for  the 
reason  previously  given.  The  aiUhor  had  made  the  forceps  shown  in 
Fig.  33.  Passing  the  esophagoscope  under  ether  anesthesia,  the  pin 
was  quickly  located,  surrounded  by  an  area  of  acute  esophagitis.     The 


352  ICSOPHAGOSCOPY  FOR   FOREIGN  BODIES. 

point  was  buried  the  full  extent  of  the  taper.  Under  ocular  guidance, 
the  author  seized  the  pin  by  the  ring,  as  shown  at  B  in  Fig.  213.  Fol- 
lowing with  the  esophagoscope,  the  pin  was  pushed  downward,  thus 
withdrawing  the  jioint  of  the  pin  from  its  bed  in  the  esophageal  wall 
and  gently  carrying  the  pin,  secure;ly  held,  but  free  to  move,  down  into 
the  stomach  as  shown  at  C,  Fig.  213.  Withdrawal  of  the  forceps  turned 
the  pin  by  the  keeper  and  the  point  striking  the  wall  of  the  stomach ; 
and  the  pin  was  pulled  into  the  esophagoscope  sufficiently  far  to  close  it, 
though  it  was  too  large  to  be  removed  through  the  tube.  The  esoph- 
agoscope, forceps  and  pin  were  all  withdrawn  together.  Dr.  Homer 
McCready,  who  manipulated  the  aspirator,  reported  no  stain  of  blood  in 
the  secretions.  The  entire  procedure  required  but  se\en  minutes.  The 
fever  subsided  in  a  few  days  and  the  child  went  home  well. 

Remarks.  The  action  of  the  forceps  will  be  understood  from  Fig. 
312.  If  the  ring  were  seized  with  the  ordinary  flat-jawed  forceps  (as  at 
F).  the  pin  could  not  be  turned  without  risk  of  losing  it  and  causing 
delay.  The  special  rotation  forceps  hold  the  pin  securely  at  the  ring 
but  allow  it  to  turn  freely  without  letting  go.  The  pin  cannot  turn  the 
full  ISO  degrees,  but  it  can  turn  far  enough  to  allow  it  to  be  drawn  into 
the  tube  where  it  is  safely  housed  for  removal.  If  a  small  pin,  it  can  be 
withdrawn  through  the  tube  as  in  the  second  case.  The  question  may 
be  asked.  Why  is  it  safer  to  turn  the  pin  in  the  stomach  than  in  the  esoph- 
agus? There  is  more  room,  so  that  there  is  no  pressure  on  the  point  of 
the  pin,  the  pin  being  free  to  turn ;  and,  most  important,  the  stomach  wall 
is  thick  and  strong  as  compared  to  that  of  the  esophagus,  though  we  must 
not  be  tempted  into  roughness  by  this.  Gastroscopic  manipulations  must 
be  gentle. 

Margaret  K.,  aged  fourteen  months,  referred  by  Dr.  F.  L.  Ives. 
A  radiograph  (Fig.  214)  by  Dr.  L.  Gregory  Cole,  of  New  York  City, 
showed  the  ])in  to  be  lodged  point  upward  in  the  esophagus.  At  the 
Eye  and  Ear  Hospital,  two  days  after  the  swallowing  of  the  pin  the 
author  removed  it  by  the  same  method  as  in  the  ]>revious  case,  but,  being 
smaller  in  size,  the  pin  could  be  withdrawn  through  the  tube.  The  child 
returned  home  well  on  the  second  day.  Illustrations  of  the  pins  are 
shown  in  Chapter  XXI. 

So  far  the  author  has  not  lost  the  pin  from  the  grip  of  the  forceps 
while  at  work  on  a  case.  Twice,  however,  in  demonstration  work  de- 
fective forceps  allowed  the  pin  to  escape.  It  was  thus  discovered  that 
the  forceps  must  be  made  exactly  as  shown  in  Fig.  33. 

D.  R.  Paterson  has  devised  a  very  ingenious  method  of  passing  a 
small  tube  over  the  point  of  the  safety  pin  and  then  catching  the  safety 
pin  by  the  other  limb  and  thus  removing  it  safely,  the  little  tube,  forceps. 


KSOPHAGOSCOPY  FOR  FOREIGN   BODIES. 


353 


pin  and  esophagoscope  all  bciug-  brought  out  together.     Alosher,   Hub- 
bard and  others  have  devised  very  ingenious  pin  closers. 

Extraction  of  double  pointed  tacks  and  staples  lodged  point  upward 
in  the  esophagus.  If  very  .short  these  objects  could  be  turned  by  grasp- 
ing them  by  the  lower  or  curved  end.  A  safer  method  and  one  that 
must  be  adojHcd  in  case  of  longer  tacks  or  staples  is  to  carry  the  in- 


Fic;.  21.^. — l.aKr.il  railiMiiiaiih  U'>  I'l-  tlcuiyc  C.  Juliii,-.l(jn  )  i.i  a  satcly  pin  in 
a  cliild  of  II  months,  demonstrating  the  esophageal  location  of  the  pin  in  this 
ciise  and  the  great  vaUie  of  the  lateral  radiograph  of  foreign  body  cases.  (.\uthor's 
case.    See  Fisrs.  272  and  212.) 


truder  down  into  the  stomach  there  to  l)e  turned  as  described  for  safety 
[lins.  The  safety  pin  or  rotation  forccjjs  (  b'ig.  :'>:>')  must  be  used.  L'nder 
no  circumstances  should  sucii  an  intruder  be  pulled  upon  with  the  ordi- 
nary forceps. 

Extraction  of  fish  hooks  from  the  esophagus.     The  author  has  never 
yet  had  to  dcrd  endoscopically  with  a  fish  hook,  but  there  are  four  nielli- 


354 


KSOPHACoSCorV   l-'OR   F(1Ki:ir..\    BODll-lS. 


ods  by  which  the  mechanical  ijroblem  can  probably  be  solved.  The  first 
of  these  is  that  bv  which  1).  R.  I'aterson  removed  a  fish  hook  from  the 
le\el  of  the  boily  of  the  fifth  dorsal  vertebra  of  a  boy  aged  thirteen 
years.  The  hook  had  the  usual  gut  leader  aljout  nine  inches  in  length 
projecting  from  the  patient's  mouth.  Dr.  Paterson  passed  the  esophago- 
scope  over  the  gut  leader  and  then  threaded  a  bronchoscopic  aspirating 
tube  over  the  leader  so  that  when  passeil  down  to  the  level  of  the  hook 
the  bulhovis  extremity  of  the  aspirating  tube  fitted  into  the  curve  of  th-^ 


Fin.  214. — Radiograph  by  Dr.  L.  Gregory  Cole,  (New  York),  showing  safety 
pin  in  the  esophagus  of  an  infant  ageil  fourteen  months.  Passed  into  the  stomach, 
turned   and   removed   under  esophagoscopic  guidance.      (Author's   case). 


hook  which  was  thus  safeguarded  and  withdrawn.  In  the  event  of  en- 
countering a  hook  that  has  an  eye  instead  of  the  gut  leader,  forceps 
could  be  used  to  thread  a  braided  silk  through  the  eye  and  then  the 
distal  end  being  brought  up  we  would  have  a  double  thread  coming  oiTt 
the  mouth.  Over  this  double  thread  the  aspirating  tube  could  be  passed 
as  was  done  by  Dr.  Paterson  in  his  case.  In  the  event  of  the  eye  being 
too  large  to  pass  through  the  as|iirating  tube,  a  similar  tube  could  be 
readily  constructed  for  the  ptu-posc  with  a  larger  lumen,  or  a  flattened 
lumen,  if  necessary.  A  second  method  would  be  to  use  the  pin  cutting 
forceps.  Fig.  o-i.  These,  however,  would  ;iroIial)l\-  not  extract  the  frag- 
ment, if  the  barb  was  buried  in  the  esophageal  wall,  though  if  properly 


KsopiiAc.osCDPV  KiiK  i'oRi;ir..\  r.oniKS.  355 

coiislriicK-(l  tlic\-  sliiiiilil  hold  the  iragnicm  if  the  barh  was  nut  hurieil. 
The  loss  of  ihi-  jioinl  wiili  the  harlj  would  ccrtainl\-  be  a  ri>ky  iinn'cdun.- 
because  of  the  certainty  of  the  barb  working  its  way  through  distant 
tissues.  While  the  patient  might  possibly  escape  serious  injury  from 
this  cause,  the  author  believes  that  the  third  method  will  be  found  the 
easiest  and  the  most  practical  as  well  as  the  most  certain.  'I'his  co.i- 
sists  in  i)assing  the  tish  hook  down  into  the  stomach,  turning  U  anil 
bringing  it  out  with  the  curve  end  first,  the  point  trailing  behind,  if  too 
large  to  pull  the  entire  curved  jiart  of  the  fish  hook  into  the  distal  end  of 
the  esophagoscope.  This  procedure  would  be  precisely  the  same  as 
mentioned  in  regard  to  safety  pins  and  fence  staples.  This  has  been  so 
re;idilv  accomplished  b\-  the  author  in  dealing  with  safety  ])ins  and  staples 
that  he  feels  (|nile  certain  that  it  could  be  even  more  readily  done  in  the 
case  of  the  fish  hook.  Pressure  downward  with  the  forcejis  after  grasp- 
ing would  certainly  extract  the  barb.  A  fourth  metluul  wuuld  be  by 
catching  the  point  and  barb  in  the  tissue  forcei)S,  Fig.  :i-"i,  after  pushing 
the  hook  (hnvnward  sul'ficiently  to  disembetl  the  barbed  end.  Thus  pro- 
tected with  the  box-like  covering  of  the  tissue  forcejis  the  intruder  could 
l)robably  be  withdrawn  harmlessly.  As  before  stated  the  author  has  had 
no  opporlimity  to  deal  with  the  fish  hook  [)roblem  in  the  human  being 
but  he  has  practiced  these  jirocedures  until  he  believes  that  each  of  then' 
can  be  done  upon  the  luunan  lieing  b\-  very  careful  work.  l'"or  such 
manipulations  he  would  deem  a  general  anesthetic  advisable  unless  abso- 
lutely contraindicated. 

Ilxtraction  of  foreign  bodies  cj  large  sirjc  from  the  esophagus.  The 
removal  of  very  large,  rough  and  sharj)  bodies,  such  as  bones  and  arti- 
ficial dentures,  from  the  esophagus  cleserves  special  consideration.  .Many 
cases  have  been  needlessly  (and  occasionally  unsuccessfully)  ojierated 
externally,  'i'he  esophagus  is  a  highly  sjiasmodic  tube.  One  of  the 
functions  of  nausea  is  to  relax  the  esojihagus  and  prevent  spasm  in  order 
to  t;u'ilitate  \omiting  though,  of  coin-se,  \omiting  can  occur  without 
nausea.  \\  hen  the  attem[)t  is  made  to  withdraw  a  foreign  body  spasm 
is  excited  and  constriction  occurs.  This  h;is  been  fre<|uentl\-  demon- 
slnited  to  others  by  the  anilior.  W  In  n  a  bodv  is  large,  sharp  and  rough 
the  spasm  excited  is  much  greater  .ind  even  if  it  were  not,  constriction 
means  more  with  such  a  body  th.an  with  a  small,  smooth.  riJinid  otie.  It 
ought  n(]t  to  re(|uire  nnich  argument  to  convince  an\-one  of  the  neces- 
sity of  the  relaxation  of  deep  general  anesthesia  for  all  cases  of  esoph- 
agoscopic  removal  of  large,  sharp  or  rough  foreign  bodies.  With 
such  relaxation  ;niy  intruder,  no  matt<-r  how  l.irge  or  sh;n-[).  lh;it  has 
.gone  down  through  natural  ])assages  can  come  up  the  s.ime  wav  :  pro- 
vided thai,  in  the  withdrawal,  as  occurred  naturalh-  in  the  intrusion    tlie 


356  ESOPHAGOSCOPY  FOR  FORICIGX   BODIKS. 

intruder  is  turned  to  the  most  favorable  position.  It  is  necessary  to  re- 
lax not  only  tlie  esophageal  musculature  itself  but  also  the  musculature 
which  acts  upon  the  surrounding  hard  and  soft  anatomic  structures,  such 
as  the  action  of  the  constrictors  on  the  cricoid  cartilage  and  even  the 
diaphragmatic  musculature  in  the  rare  cases  of  withdrawal  of  a  foreign 
body  from  below  the  hiatal  level.  In  case  of  small  foreign  bodies,  the 
relaxation  of  deep  anesthesia  may  lose  the  intruder  downward.  In  large 
impacted  bodies  there  is  no  likelihood  of  this,  but  procedure  must  be 
careful  to  avoid  respiratory  arrest  as  before  mentioned. 

IMillspaugh  (Bib.  383)  in  a  very  interesting  paper,  reports  the  re- 
moval of  a  large  vulcanite  plate  on  which  were  two  teeth,  demonstrating 
clearly  what  careful  manipulations  can  do  in  the  removal  endoscopically 
of  these  large  foreign  bodies  which  heretofore  have  been  considered  as 
demanding  external  operation.  The  interesting  case  of  esophagoscopic 
removal,  by  Dr.  D.  Braden  Kyle,  of  a  vulcanite  tooth  plate  is  reported 
in  a  subsequent  paragraph. 

In  exceptional  cases  it  may  be  necessarv  to  comminute  a  large  for- 
eign body,  as  was  done  by  Killian  with  rare  skill  in  case  of  a  vulcanite 
tooth  plate. 

Extraction  of  nwat  and  other  foods  from  the  esophagus.  Meat  in 
the  esophagus,  after  it  has  become  macerated,  can  sometimes  be  re- 
moved very  readily  with  forceps.  In  many  cases,  hovv^ever,  the  mechan- 
ical spoon.  Fig.  40,  will  be  found  verv  much  better,  inasmuch  as  it  can  be 
placed  belovi'  the  meat,  the  spoon  turned  up  and  the  meat  pulled  en  masse 
into  the  mouth  of  the  esophagoscope. 

Extraction  of  foreign  bodies  from  the  strictiired  esophacjns.  At 
first  thought,  it  might  seem  unusual  to  have  the  combination  in  the  same 
case  of  a  stricture  of  the  esophagus  and  a  foreign  body.  Yet  such  a  com- 
bination is  by  no  means  infrequent.  Foreign  bodies  of  relativelv  small 
size  will  lodge  in  a  strictured  esophagus,  but  would  pass  through  a 
norma!  gullet.  Children,  especially,  will  fail  to  masticate  food  thorough- 
ly, or  will  allow  the  foreign  body,  such  as  chewing  gum,  grape  pulp,  in- 
cluding the  seeds,  orange  seeds,  watermelon  seeds,  and  the  like,  to  slip 
down.  The  author  had  one  case  where  he  removed,  at  diiTerent  times, 
four  different  foreign  bodies  from  the  esophagus  of  one  child  under- 
going treatment  for  stricture.  The  situation  becomes  still  more  com- 
plicated when  the  patient  has  an  upper  stricture  relativelv  larger  than 
the  lower  one,  and  the  foreign  body  passing  the  first  one  lodges  at  the 
second,  and  still  more  difficult  is  the  case  if  the  second  stricture  is  con- 
siderably below  the  first  and  not  concentric.  Under  these  circumstances, 
it  is  best  to  divulse  the  upper  stricture  mechanically  with  the  divulsor 
shown  in  Fig.  'i2,  when  a  small  tube  can  be  inserted  past  the  first  stric- 


ESOPHACOSCOl'Y  I'OR   I'OKKIf.N   BODIKS.  357 

lure,  thus  at  tlic  same  lime  simplifying  tlie  removal  and  accomplishing 
one  stage  of  the  treatment  for  the  stenosis.  In  some  of  these  stricture 
cases  bismuth  may  completely  occlude  the  lumen  of  the  stricture  when 
given  in  the  large  quantities  sometimes  required  for  a  radiograph.  This 
is  much  less  apt  to  follow  a  mixture  of  bismuth  with  milk  than  with 
bread  or  porridge.  In  either  case  it  is  not  difficult  to  remove  the  bismuth 
esophagoscopically,  using  the  sponges  in  the  sponge  holder,  and,  if  neces- 
sary, the  mechanical  spoon  until  the  lumen  of  the  stricture  is  reached, 
when  the  opening  may  be  found  'vith  a  small  jirobe,  and  afterwards  small 
olives  can  be  passed.  The  surplus  bismuth  should  be  removed  upward 
so  as  not  to  occlude  the  canal  again.  Usually  such  patients  can  regurgi- 
tate a  large  jiart  of  the  contents  of  the  esojihagus,  and  it  remains  only 
for  the  esophagoscopist  to  clean  out  the  remainder  by  the  means  men- 
tioned. 

Extracluni  of  fovc'uin  bodies  after  prolonged  sojourn  hi  the  esoph- 
agus. The  leading  case  is  that  of  D.  IJraden  Kyle  (Bib.  3V.>).  A 
tooth  plate  had  remained  in  the  esophagus  for  eighteen  years.  A  phy- 
sician called  shortly  after  the  accident  assured  the  patient  that  the  teeth 
were  not  in  the  esophagus  on  the  strength  of  a  negative  result  with 
bougies  and  jjrobangs.  The  tooth  plate  was  located  radiographicall)' 
'Fig.  S]-")).  With  the  esophagoscope,  Dr.  Kyle  found  the  foreign  body 
eighteen  centimeters  from  the  upper  teeth.  The  upper  edge  was  cov- 
ered with  fibrous  tissue.  At  four  sittings.  Dr.  Kyle  in  his  careful,  skill- 
ful way  disimpacted  and  removed  the  tooth  plate  from  its  bed.  The 
patient  had  slight  difficulty  in  swallowing  for  a  time,  but  in  three  months 
could  readily  swallow  semisolid  food. 

In  these  cases  of  prolonged  sojourn  ui  the  foreign  body  in  the  esoph- 
agus, the  inflammatory  exudate  will  contract  after  the  foreign  body 
is  removed  and  stricture  of  greater  or  less  extent  is  almost  certain  to 
follow,  so  that  in  all  such  cases,  it  is  wise  to  keep  a  close  watch  on  the 
patient,  and  if  stricture  follow,  it  should  be  treated  bv  the  same  methods 
as  other  cicatricial  stenoses,  to  be  considered  later. 

Foreign  bodies  buried  in  Pha>-yn(/eal  and  esopha(/eal  tissues.  In 
cases  of  needles,  headless  pins  an<l  tin-  like  haxing  entered  and  disap- 
peared in  the  tissues  of  the  pharynx,  they  should  be  followed  through 
the  wound  of  entrance  if  this  can  be  found.  Otherwise,  the\-  should  be 
searched  for  l.y  finger  palpation  aided  by  accurate  localization  witli  both 
an  anteroposterior  and  a  lateral  radiograjih.  When  tints  located  an  in- 
cision should  be  made  crosswise  to  the  long  axis  of  the  pin.  This  is  im- 
lierali\e,  because  if  the  incision  is  parallel  the  ch.uiccs  of  striking  the  pin 
are  remote.  Two  cases  of  this  kind  were  seen  in  the  autiior's  service 
at  the  Eye  and  Ear  Hospital.     In  one  of  these,  previously  reported  (Bib. 


358 


F.POPHAC.OSCni'Y   KOR   FORlvIGN    BODIKS. 


2(!St,  page  ]'27),  a  doulik-  i>()inti.-il  pin  had  wandered  from  the  wound  of 
entrance  and  was  removed  from  the  posterior  wall  of  the  laryngopharynx. 
In  the  second  case,  that  of  a  needle  in  the  tissues  back  of  the  hypo- 
pharvnx  of  a  woman  of  fnrtv  years,  the  needle  was  accurately  located  Ijy 
anteroposterior  and  lateral  radiographs  by  Dr.  Russell  H.  Boggs.  It 
could  not  he  palpated  because  of  its  depth;  but  by  an  endoscopic  estimate 
of  the  radiographically  determined  distance  of  the  center  of  the  long 
axis  of  the  needle  upward  from  the  cricoid  cartilage,  a  crosswise  in- 
cision with  the  long  laryngeal  knife  (Fig.  85)  passed  through  the  eso- 
phageal speculum  (Fig.  "M  ),  the  author  w'as  so  fortunate  as  to  strike  the 


Fig.  215. — Radiograph  showing  tcoth  plait  in  ihc  csophagns  where  it  had  been 
for  18  years.     (Removed  by  Dr.  D.  Braden  Kyle). 


needle  at  the  first  incision.  The  wound  was  covered  with  bismuth  sub- 
nitrate  by  insufflation.  Dismuth  was  ordered  in  five  grain  doses  dry  on 
the  tongue  every  hour.  Healing  was  complete  in  about  a  week,  without 
any  rise  of  temperature  or  complication  except  slight  subcutaneous 
emphysema  which  subsided  in  a  few  days.  When  foreign  bodies  have 
invaded  the  intrathoracic  periesophageal  tissues,  it  is  unwise  to  make 
an  incision  to  reach  them,  and  even  through  the  wound  of  entrance  it  is 
unwise  to  pursue  them  far.  It  is.  howe\er,  justifiable  in  cases  in  which 
there  is  local  or  radiographic  evidence  of  a  buried  foreign  body,  care- 
fully to  explore  the  wound  b\-  instrumental  palpation.     The  best  explor- 


KSOPIIAC.OSCOl'V   I'OK   l'(IRl-JC,\    i;()DIES.  359 

ing  inslrumcnt  for  this  i)urpose  is  the  forceps.  Fig.  28,  which  are  inserted 
closed.  Should  the  exjiloration  transmit  the  sensation  of  a  foreign  body 
the  forceps  are  expanded  and  the  foreign  body  is  seized.  This  explora- 
tion refers  onlv  to  recent  cases  with  a  \isil)le  woimd  of  entrance  or  those 
in  which  the  wound  channel  is  marked  by  granulation  tissue.  Where  the 
foreign  body  has  perforated  the  anterior  esophageal  wall  at  any  point 
above  the  tracheal  bifurcation,  the  foreign  body  may  be  found  in  the 
trachea  of  which  an  instance  is  elsewhere  herein  reported.  If  there  is 
no  wound  \isible,  fluoroscopic  aid  for  localization  may  be  sought  as  else- 
where mentioned,  but  great  care  must  be  used. 

As  pointed  out  by  Ingals  li'.ib.  -i-ii)) — "An  operator  must  not  too 
readily  conclude  that  something  w  iiich  to  him  appears  unnatural  is  the 
wound  through  whicii  a  coin  or  InUlon  that  cannot  be  found  has  made 
its  way  into  the  esophageal  wall,  for  in  the  great  majority  of  cases  it 
would  be  very  much  more  likely  that  such  a  foreign  body  was  hidden  by  a 
fold  of  edematous  tissues."  I'nder  no  circumstances  is  it  justifiable  to 
explore  except  in  the  most  gentle  way  an  apparent  wound  in  the  eso- 
phageal wall  and  even  careful  exploration  should  not  be  atteinpleii  until 
the  entire  esophagus  has  been  explored  for  the  foreign  body  and  ;i  radio- 
graph has  been  taken  to  determine  whether  or  not  the  foreign  body  has 
emerged  through  the  eso])hageal  wall.  The  author  has  seen  five  cases 
of  abscess  of  the  esophagus  from  foreign  body  traumatism  and  in  two 
of  the  cases  the  foreign  body  was  lodged  inside  the  abscess,  in  one  such 
case  of  the  autlior,  referred  by  T^r.  Clarence  M.  Harris,  the  patient  was 
unal)le  to  swallow.  I'lJon  i)assage  of  the  esophagoscope  the  esophagus 
was  found  occluded  at  the  level  of  tlic  lower  liorder  of  the  cricniil  by  a 
smooth  rounded  swelling  on  the  ajiex  of  which  was  a  small  crater-like 
opening.  The  pressure  of  the  tube  caused  pus  to  exude  and  the  abscess 
was  thus  completely  exacuated.  The  patient  b;id  no  further  difliculty  in 
swallowing  though  there  was  slight  odynphagia  for  a  few  da_\s  during 
which  bismuth  subnitrale  and  calomel  were  given.  Comjilete  recovery 
res'.dted  in  one  week.  .\f)  foreign  boily  was  found  in  the  jms  .nul  it 
was  (|uite  clear  that  the  abscess  resulted  simply  from  the  infectixe  intlam- 
mation  of  the  ])micture  of  tlie  foreign  hotly,  a  bone. 

Flitroscopic  csopluifioscopy  seems  to  the  .-nUhor  an  unjustifiable  pro- 
cedure. In  case  (if  foreign  bodies  tliat  have  entered  bronchi  too  small 
for  an  endosc(jpic  lube  to  enter,  the  foreign  body  cannot  be  found  ex- 
cept by  relatively  blind  endoscopic  melbi)ds  ami  therefore  fluoroscoi)ic 
bronchoscopy  may  have  a  legitimate,  tiiougb  limited,  field  of  usefulness, 
r.ut  in  the  esophagus  where  every  S(|uare  millimeter  of  surface  is  explor- 
able  by  sight,  Huoroscoi)ic  esophagoscopy  is  a  step  backward  that  is  un- 
justifiable.    .\   jiossible  use   for  the  tlunroscoi)e  in   this  comiection   would 


360  ESOPHAGOSCOPY  FOR  FOREIGN   EDDIES. 

be  in  a  case  of  a  foreign  body  having  wandered  out  tlirough  the  esoph- 
ageal wall.  ir.  which  case  it  is  no  longer  a  foreign  body  in  the  esoiihagns. 
To  pursue  it  under  fluoroscopic  guidance  would  be  more  danger- 
ous than  external  operation.  If  the  latter  is  not  advisable  at  once  the 
wanderings  of  the  invader  can  be  watched  radiographically  and  oper- 
ation deferred  until  the  foreign  body  reaches  a  favorable  location.  In 
case  a  foreign  body  shows  clearly  in  a  radiograph,  after  the  esophago- 
scopic  search  has  proven  negative  and  no  wound  of  entrance  is  discov- 
erable, it  is  advisable  to  use  the  fluoroscope  to  obtain  accurate  localiza- 
tion of  the  position  of  the  foreign  body  simply  to  explore  the  wound 
endoscopically  under  ocular  guidance  to  the  limited  extent  such  explora- 
tion may  be  deemed  advisable.  Unfortunately  this  can  be  done  only  in 
very  recent  cases  and  even  in  these  the  intruder  may  have  traveled  far, 
so  that  it  may  be  nowhere  near  its  wound  of  entrance.  It  is  usually  pins, 
needles  and  similar  slender,  sharp  pointed  bodies  that  escape  through 
the  esophageal  wall.  The  author  had  one  case,  that  of  a  common  pin 
that  had  escaped — all  but  the  head.  He  was  fortunately  able  in  this  par- 
ticular instance  to  find  the  head  endoscopically  and  remove  the  pin ;  but 
he  can  easily  see  how  information  from  the  fluoroscopist  working  jointly 
with  the  endoscopist  could,  in  such  a  case,  give  assistance  of  the  utmost 
value,  especiallv  with  the  <loul)le-pIane  fluoroscope  dexised  for  the  author 
by  Dr.  drier. 

In  cases  of  bodies  of  irregular  shape  the  fluorescent  screen  affords 
no  evidence  whatever  that  the  foreign  body  is  being  so  seized  that  it  will 
not  lacerate  the  esophagus  during  withdrawal. 

As  mentioned  by  D.  R.  Paterson  injurv  has  been  done  by  fluoro- 
scopic esophagoscopy.  While  successful  in  some  cases  with  smooth  for- 
eign bodies  the  fluorescent  screen  does  not  enable  the  operator  to  make 
sure  that  he  is  not  seizing  any  mucosa  along  with  the  foreign  body.  As 
stated  by  D.  R.  Paterson  and  concurred  in  by  all  other  esophagoscopists 
of  experience  "It  is  surely  more  in  accordance  with  surgical  principles  to 
see  a  foreign  body  in  situ,  and  so  define  its  relations  to  the  surrounding 
esophagus." 

Complications  and  dangers  of  esophagoscopy  for  foreign  bodies. 
Asphyxia  from  pressure  of  the  esophagoscope.  plus  the  bulk  of  the  for- 
eign body,  or,  in  some  instances,  by  the  foreign  body  alone  without  any 
esophagoscopy,  is  a  possibility.  The  danger  of  the  esophagoscope  causing 
asphyxia  is  enormously  increased  by  general  anesthesia.  The  author's 
schematic  representation  of  this  (P.ib.  2(!9,  p.  14';),  has  been  abundantly 
born  out  by  frequent  reports  of  deaths  on  the  table  during  esophagoscopy, 
and  especially  esophagoscopy  imder  general  anesthesia.  Such  a  possi- 
bility is  very  much  greater  with  chloroform  than  with  ether,  because  of 


ESOPIIACOSCOPY  I"OK  rOKKlGN   nODIKS.  361 

the  stimulant  effect  of  ether  on  the  respiratory  center,  and  the  paralytic 
effect  of  chloroform.  Cocaine  poisoning,  due  to  the  use  of  an  anesthetic 
solution,  or  of  too  strong  a  solution,  has  been  reported.  The  viselessness 
of  local  anesthesia  for  esophagoscopy  has  been  elsewhere  mentioned.  If 
local  anesthesia  is  ever  needed  for  esophagoscopy,  it  certainly  can  be 
needed  only  in  the  one  pyriform  sinus,  through  which  the  esophagoscope 
is  to  be  passed.  In  making  the  application  to  the  pyriform  sinus,  there 
will  be  enough  of  the  solution  applied  to  the  pharynx  inevitably  by  the 
spread  of  the  secretions,  so  that  no  special  application  is  needed,  except 
in  the  [lyriform  sinus.  Such  a  limited  apjilication  can  involve  no  special 
risk  in  adults.  Children  are  very  susceptible.  Septic  mediastinitis  with 
cellulitis  of  the  neck  has  been  seen  three  times  in  consultation  by  the 
atuhor.  He  advised,  in  each  case,  and  upon  request,  performed  in  one 
of  the  cases,  a  drainage  of  the  region  back  of  the  esophagus  by  a  long 
incision  along  the  sternal  mastoid  muscle,  with  dry  dissection  deep  down 
along  the  esophagus  uiuil  the  perforation  was  found.  In  two  of  the 
cases,  perforation  had  been  caused  by  the  foreign  body ;  in  one  instance 
spontaneously,  and  the  other  in  removal.  The  third  case  was  caused  by 
perforation  by  the  blind  passage  of  a  bougie.  In  both  of  the  cases 
emphysema,  with  intense  dyspnea,  followed  immediately  after  the  acci- 
dent, requiring  tracheotomy  in  two  of  the  cases.  The  cellulitis  developed 
witlun  forty-eight  hours.  All  of  the  cases  recovered  after  drainage. 
Perforation  of  the  esophagus  by  either  the  foreign  bodv  or  by  the  esoph- 
agoscope. may  occur.  The  foreign  body,  especially  sharp  pointed  pins 
and  bones,  may  erode  its  own  way  through  the  esophagus  either  by  ulcer- 
ation or  even  by  direct  puncture,  but  much  more  frequently,  the  introduc- 
tion of  instruments  blindly,  or  even  occasionally  the  introduction  of  the 
esophagoscope  may  force  the  foreign  body  through  the  wall.  Very 
careful  work  will  prevent  any  assistance  to  perforation  during  esoph- 
agoscopy, but  the  possibility  should  be  borne  in  mind.  In  regard  to 
perforation  of  the  wall  with  the  eso])hagoscope,  such  a  thing  is  exceed- 
ingly rare  in  skillful  bands  and  with  a  sound  esophageal  wall.  It  nuist 
be  borne  in  mind,  however,  that  the  esophageal  wall  may  be  weakened 
by  ulceration,  or  by  malignant  disease,  or  aneurysm  so  that  the  tube  will 
meet  with  jjractically  no  resistance  in  making  a  false  passage.  As  else- 
where mentioned,  the  greatest  danger  exists  in  the  neighborhood  of  the 
cricoid  level  from  the  contraction  of  the  annular  fibers  of  the  crico- 
jiharyngeus.  The  most  serious  accident  that  can  occur  is  a  gangrenous 
esophagitis  which  is  almost  invariably  fatal.  Such  a  complication  can 
occur  only  from  the  most  gross  and  brutal  attempts  by  one  who  is  not 
only  totally  ignorant  of  the  procedure,  but  is  not  ordinarily  careful  in  his 
manipulations  and  who  is  not  careful  of  his  ascjitic  technic.     The  worst 


362  KSOPHAGOSCOPY  FOR  FOREIGN   BODIF.S. 

case  of  gangrenous  csopliagitis  that  the  author  ever  saw  was  due  to  bHnil 
attempts  to  remove  a  foreign  body  which  probablv  was  not  present. 
Forceps  had  been  used  bhndly  on  what  the  surgeon  told  the  relatives 
was  a  bone  that  he  could  feel.  At  autopsy,  the  bone  proved  to  be  the 
cervical  vertebrae,  the  bodies  of  three  of  which  were  denuded.  The 
surgeon,  who  had  never  previously  bandied  an  esophagoscope  attempted 
esophagoscopy,  and  failing  in  that,  resorted  to  the  blind  use  of  powerful 
forceps.  The  symptoms  are,  profound  shock,  high  temperature  early  in 
the  case  and  a  subnormal  temperature  later,  a  weak  rapid  pulse,  great 
restlessness,  low  moaning  or  muttering  delirium,  and  quite  characteristic 
is  the  putrid  odor  of  the  breath. 

Treatment.  The  treatment  of  acute  esophagitis  consists  in  rest,  ster- 
ile licjuid  food,  and  the  administration  of  small  doses  of  bismuth  and 
calomel  frequently  repeated.  The  calomel  may  be  discontinued  when  it 
acts  too  freely  on  the  bowels,  and  the  bismuth  continued  alone.  Local 
applications  of  cold,  such  as  with  an  ice  bag,  can  be  used  where  the 
trouble  is  in  the  cervical  esophagus.  Rest  of  the  esophagus  is  best  ac- 
complished b}-  gastrostomy  for  the  giving  of  food  and  liquid,  Imt  in  the 
class  of  case  now  under  consideration,  gastrostomy  would  be  rarely  ad- 
visable. The  teeth  and  mouth  should  be  kept  in  as  clean  condition  as 
possible,  and  alcohol,  "i.")  per  cent,  should  be  used  to  rinse  the  mouth  at 
least  once  an  hour.  This,  with  sterile  food,  will  limit  the  activity  of  the 
mixed  infections,  which  are  the  most  dangerous  complications  after  eso- 
phageal trauma.  Emphysema  does  not  usuallv  re(|uire  anv  si>ecial  treat- 
ment for  the  leak  soon  becomes  obliterated  and  if  no  infective  conditions 
follow,  the  emphysema  will  usually  subside  itself.  An  occasional  case, 
however,  may  be  encountered  where  it  is  necessary  to  puncture  the  skin 
in  many  places  in  order  to  liberate  the  air,  though  the  author  has  never 
yet  seen  such  a  case.  In  the  event  of  the  pleura  being  perforated,  imme- 
diate signs  of  shock  and  pleuritis  are  apt  to  develop  and  pneumothorax 
will  show  its  characteristic  signs  within  twelve  hours.  If  tapped  imme- 
diately, there  may  he,  in  this  short  time,  the  characteristic  fecal  odor  from 
bacterial  activity.  If  the  mediastinum  has  not  also  been  infected,  a 
proni[)t  ojicning  of  the  pleura  may  sa\e  the  patierit. 


CHAPTER     XX. 

Pleuroscopy. 

Pleuroscopy  for  foreiyn  bodies.  The  author  has,  in  one  instance, 
removed  a  foreign  body,  a  primer  from  a  shotgun  cartridge.  Figs.  21  ti 
and  217,  from  the  pleural  cavity  through  a  small  opening  made  in  the 
chest  by  Dr.  J.  Hartley  Anderson.  This  was  done  immediately  after  the 
accident  and  there  was  no  odor  or  pus  at  anv  time.  General  anesthesia 
was  given,  and  the  child,  after  the  chest  opening  was  made,  was  placed 
in  the  sitting  position  in  order  that  the  foreign  body  would  fall  to  the 
diaphragm.  Healing  was  prompt  and  the  air  began  to  enter  the  lung 
on  the  fifth  day.  The  child  made  a  prompt  recovery,  and  now,  about 
three  years  after  ihe  uperation.  is  in  iierfect  health.  In  this  class  of 
cases,  pleuroscopy  promises  excellent  results  if  done  immediately,  before 
infection  or  inflammation  has  set  in.  ( )nly  a  small  opening  is  necessary, 
and  this  does  not  invoke  anything  like  the  shock  consequent  upnn  the 
large  osteo]dastic  fia]).  The  only  shock  is  the  pleural  shock,  which  is 
slight,  and  which  in  the  author's  case  was  ])resent  anyway  because  there 
was  already  ;i  I'luiimothorax  before  the  chest  was  opened.  'IMie  instru- 
ment used  by  the  author  was  the  adult  esophageal  specidum  (Fig.  2\) 
with  liandle  detached.  This  instnunent  ga\e  a  large  \iew,  and  the  spat- 
ular  end  was  \ery  con\enient  lor  moving  tlie  lung  out  of  the  \v;i\\  as  the 
greatest  difficulty  encountered  was  in  the  manipulation  of  the  lung,  which 
was  flopping  about  like  a  live  fish  dangling  at  the  end  of  a  fishing  line.  .\ 
small  drain  was  put  in  as  a  precaution.  The  absence  of  pus  or  an\  cnn- 
siderable  C|uantity  of  secretion  raises  the  c|uestion  as  to  whether  or  not  it 
would  have  been  better  to  have  closed  the  wound  tightly  and  aspirated 
the  pleural  air.  It  would  seem  that  the  possibility  of  a  valvedike  action 
of  either  the  parietal  or  the  visceral  ])leur;i  |)ermitting  leakage  ;inil  com- 
pression of  the  mediastiiuim  and  other  lung,  seriouslv  imjiairing  the  nega- 
tive pressure  needed  to  make  the  other  hmg  serviceable,  wotdd  involve 
grave  risk. 

\\'hether  done  by  ])lcuroscoi>y  or  not.  immediate  remo\al  of  a  foreign 
body  as  soon  as  it  is  discovered  in  the  lung  is  advisable. 


364 


PLKUEOSCOPY. 


Fleuroscopy  offers  no  hope  of  finding  foreign  bodies  still  in  tlie  huig. 

Plcuroscot'V  tor  disease,  rieuroscopy  for  exploration  and  treat- 
ment of  pleural  diseases  is  quite  feasible  through  a  relatively  small  open- 
ing without  rib  resection.     It  is,  of  course,  to  be  thought  of  only  when 


Fig.  2i6. — Radiograpii  showing  luicigii  body  (.primer)  at  the  bottom  of  the 
pleural  cavity  of  a  child  of  four  years.  Foreign  body  (Fig.  217)  removed  by 
pleuroscopy.     (Author's  case.) 


9 


FiG.  217.— Primer  removed  from  the  pleura  of  a  boy  of  four  years  by  pleuros- 


copy. 


for  some  reason,  a  large  opening  is  not  desired.  Most  pleural  diseases, 
however,  require  a  large  external  opening  for  drainage  and  these  permit 
inspection  without  endoscopy,  though  even  in  case  of  large  openings  the 
esophageal  speculum  by  its  light  and  its  spatular  use  in  the  moving  aside 
the  lung  is  a  great  aid  to  exploration  in  the  otherwise  dark  pleural  cavity. 


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401 


CHAPTER     XXI. 

Illustrative  Cases  of  Endoscopy  for  Foreign 
Bodies  in  the  Air  and  Food  Passages. 

As  the  factor  paramount  m  peroral  endoscopy  is  the  mechanical  prob- 
lem of  extraction,  and  as  this  problem  is  dominated  by  the  nature  of  the 
foreign  body,  the  following  cases  are  grouped  by  the  character  of  the  in- 
truder rather  than  by  chronological  or  anatomic  data,  so  that  the  endos- 
copist about  to  deal  with  a  foreign  body  case  may,  without  unnecessary 
delay  in  page-turning  for  cross-references,  see  the  problem  similar  bodies 
have  presented,  and  how  they  were  dealt  with,  successfully  or  unsuc- 
cessfully. For  similar  reasons  subordinate  matters,  such  as  previous 
bronchoscopies  by  other  operators,'''  symptoms,  and  even  entire  cases  of 
no  particular  interest  have  been  omitted.  The  fundamental  importance 
of  the  duration  of  the  operation  being  recognized  by  all  endoscopists,  it 
is  given  under  "Time,"  if  recorded.  If  this  were  invariably  done  by  all 
endoscopists,  an  approximate  estimate  of  the  advisable  time  limit  would 
soon  be  obtained.  The  location  at  the  time  of  removal  and  the  length 
of  sojourn  are  given  together,  though  it  was  not  always  known  how  long 
the  intruder  had  been  in  the  particular  location  stated. 

It  will  be  noted  that  chloroform  is  mentioned  in  the  earlier  cases. 
This  is  no  longer  used  by  the  author,  except  that  if  ether  fails  to  produce 
complete  relaxation  in  the  cases  of  very  large  and  very  sharp  foreign 
bodies  in  the  esophagus  a  little  chloroform  may  be  added  for  relaxation 
after  the  stimulant  effect  of  ether  makes  chloroform  safe.  All  the  late 
cases  in  children  were  done  without  anesthesia,  general  or  local.  "Point 
of  seizure"  refers  to  the  part  of  the  foreign  body  seized  or  the  manner 
of  seizing  it.  The  rotation  forceps  come  together  only  at  the  points  thus 
permitting  rotation  to  the  position  of  least  resistance  during  withdrawal 
or  such  rotation  as  would  facilitate  the  disimpaction  of  one  point  of 
pointed  transfixed  bodies,  as  explained  in  the  two  sections  on  "Mechanical 
Problem.s."  "Alligator  rotation"  forceps  (Fig.  210)  are  used  through 
the  laryngoscope  and  esophageal  speculum.  Where  simply  "alligator" 
is  given,  it  refers  to  an  elongated  form  of  Mosher's  alligator  forceps. 
The  cases  include  those  done  by  Dr.  Ellen  J.  Patterson  as  well  as  those 
by  the  author. 

As  illustrations  of  modern  coins  is  forbidden  bv  law,  special  permis- 
sion was  obtained  from  the  United  States  Government  for  the  making 
and  publishing  of  the  illustrations  below. 

•In  about  45  per  cent  of  the  cases  here  recorded  removal  had  been  previously 
attempted  by  others.  About  15  per  cent  arrived  in  a  serious  state  from  trauma  of 
roug:h  attempts.  In  many  cases  the  mechanical  problem  had  been  converted  from 
a  very  simple  into  a  very  difficult  one.  Moribund  cases  are  not  included  here 
because  no  endoscopy  was  done  by  the  author.  All  of  which  may  be  dismissed 
from  consideration  further  than  to  state  that  if  a  foreign-body  endoscopy  cannot 
be  done  carefully  it  had  better  not  be  done  at  all. 


ILLUSTKATIVK   CASES  OF  ENDOSCdrV    I'uk    l-dKKTC.X    BODIES. 


40S 


Fig.  .-^-o. — Radio^raiilis,  lateral  and  anttro|iostcrior,  showing  tack  in  left  main 
brnnchiis  iif  a  lioy  of  dt-vcn  years.  Tack  removed  by  oral  bronchoscopy  witlnnit  anes- 
thesia.    (Radio.uraphs  made  by  Dr.  George  VV.  drier.    Author's  case.^ 


404  Il.Ll'STRATlVU   C.\Si;s  111"    IvMlOSCOPV    I'OR    I*nRKl(;N    liODIKS. 


Fig.  371. — Radiographs,  lateral  and  anteroposterior,  sliovving  tack  in  loft  main 
bronclui?  of  a  boy  of  eight  years.  Tack  removed  by  oral  bronchoscopy  without 
anesthesia.     (Radiographs  by  Dr.  George  \V.  Grier.     Author's  case.) 


II.I.USTKATIVl-;    CASi:s   Ol-'    KNDOSCOI'V    I-IIR    I'ORIUCN    HODIIIS. 


405 


Fi(-.  T,~2. — Aliscess  in  n^ilu  lun.tj  c,[  a  lju\  j_j  nKnuli-  uUl.  The  ])camil,  wlikMi 
caused  the  abscess,  docs  not  sliow.  Peanut  removed  and  abscess  evacuated  by  oral 
bronchoscopy  without  anesthesia.  Shadow  strengthened  f(ir  photo-cngravinR. 
( Autlior's  case.) 


406 


ILLl'STRATIVE   CASES  OF  ENDOSCOPY    FOR   FOREIGN    BODIES. 


Fig.  373. — Radiograph  showing  stickpin  in  left  bronchus  of  a  boy  of  fifteen 
years.  Pin  was  removed  by  oral  bronchoscopy.  Radiograph  made  Ijy  the  roent- 
genologist of  the  German  Hospital,  Philadelphia.     (.Author's  case.) 


ILLUSTRATIVE    CASES    OE    ENDOSCOPY   lOR   FOREIGN    BODIES.  407 


Fig.  3-4,— RadioKraplis,  lateral  ami  aiUerupublerior,  sliowiny  shawl  pin  in  the 
left  main  bronchns  (head  in  upper  lobe  hroncluis)  of  a  girl  of  twelve  years.  Re- 
moved by  oral  bronchscopy.  (Radiograph  made  by  Dr.  George  C.  Johnston.  Au- 
thor's case.) 


408 


ILI^USTKATIVK   CASl';s  Ol"   ICNDOSCOPY    FOR    l-NJRlCli'.N    HODlliS. 


Flu.   ,^75. — Radiograiihs,   showing   pin    in    rij;lit   iironchiis   of   a   boy    aged    four 
years.    Pin  removed  by  oral  bronclioscopy.     (Radiograph  by  Ur.  Russell  H.  Boggs) 
Pin  shadow  strengthened  for  photo-engraving.     (Author's  case.) 


ILLUSTKATI\-|-;   CASKS  ni'   KM'.OSCOPV    KOK    I-HKICIGN    BOUIKS. 


4UU 


Fk;.  37(>. — RadioLsrapli  sliowinj;  slmc  Imllon  dmly  iiictal  part  dense  cnoiigli  l'< 
show)  in  left  main  1)roni-hus  of  a  girl  of  seven  years.  Distortion  gives  appearance 
of  median  position.  J-eft  Inng  atelectatic.  Compensatory  emphysema  of  right  hmg. 
Bntton  was  aspirated  three  months  previonslv.  Removal  hy  oral  hronchoscopy 
without  anesthesia,  a  hook  being  inserted  in  the  eye  of  the  button.  (  Radiograpl 
by  Dr.  George  C.  Johnstin.     .\iithor's  r:uc  ) 


4J0  ILLUSTRATIVE    CASES    OF    ENCOSCOPY   FOR   FOREIGN    BODIES. 


Fig.  377. — Radiograph  showing  pclil)le  in  right  bronchus  of  a  girl  eight  years 
of  age.  Removed  by  oral  bronchoscopy.  (Radiograph  by  Dr.  George  C.  John- 
ston.   Author's  case. ) 


ILLUSTRATIVK    CASES    OF    KNDOSCOPY   FOR   FOREIGN    BODIES.  411 


Fig.  378.^Foot  of  alarm  cltuk  in  left  lironcluis  of  child  of  four  years.  Present 
25  days.  Pneumonic  consolidation  of  left  lung.  Intruder  removed  by  oral  bron- 
choscopy. Radioifrajib  one  month  later  showed  lung  normal.  (Radiograph  by 
Dr.  George  C.  Johnston.  Author's  case.1 


F'G.  ^7')■ — Collar  liuttnn  in  c-supbiigus  of  infant  twi'lvo  months  old.  Removed 
by  specular  esophagoscopy.  (  Radiofiraiiji  by  I'r.  (ieorgc  C.  Johnston.  .\uthor's 
case.) 


412  ILIvUSTRATI\'l':    CASnS  OF   liNDOSCOPV    I'dK    FORKIGN   BODIi:s. 


Fig.  380. — Staple  (duuble-pointed  tack)  in 
stomach,  endoscopically,  turned  and  removed. 
Boggs.     Author's  case.) 


csiipha);iis.     Intnukr 
(Radiograph    by    Dr. 


passed    into 
Russell   H. 


ILLUSTRATIVE  CASKS  OF  KNDOSCOPY   I'OR  FOREIGN  BODIES. 


413 


Fig.  .?8i. — Fiii>;cT  riiiy  in  csopliayiis,  ahinc  hrDiicliial  crossing,  of  a  child  of 
ten  months.  Ut-movcd  hy  oral  csopha.uoscory  without  anesthesia.  (ka<hogra|)h  hy 
Dr.  rviissell  H.  l'.o«','s.  Author's  c;isf.) 


414  ILLUSTRATIVE   CASES  OF   ENDOSCOPY    FOR   FOREIGN    BODIES. 


Fig.  382, — Radiograph  showing  button  ni  esopliagu^  of  infant  sixteen  months 
old.  Removed  by  specnlar  esophagoscopy  without  anesthesia.  (Radiograph  by  Dr. 
King.    Author's  case.) 


Fig.  383. — Radiograph  showing  coin  (Enghsh  half-penny)  in  esophagus  of  a 
girl  five  years  of  age.  Removed  by  specular  esophagoscopy  without  anesthesia. 
(Radiograph  by  Dr.  George  W.  Grier.    Author's  case.) 


ILLUSTRATIVE    CASES    OF    ENDOSCOPY   FOR   FOREIGN    BODIES. 


415 


Fu;.  384. — Radiograpli  showiiiy  cuin  (Canadian  twciitj -five  cent  piece)  in  tlic 
esophagus  of  a  child  of  two  years.  Coin  removed  by  esophagoscopy.  (Radio- 
graph by  Dr.  Russell  H.  Boggs.    Author's  case.) 


Fig.  385. — Radiograph  showing  fragment  of  hone  in  the  trachea  of  a  woman 
of  39  years.  Bones  are  not  likely  to  show  in  an  anteroposterior  view  and  this 
radiograph  shows  how  readily  a  bone  low  in  the  neck  might  be  missed  in  a 
lateral  radiograph.  Bone  removed  by  oral  bronchoscopy.  (Radiograph  by  Dr. 
George  C.  Johnston.    Author's  case.) 


41 G  ILLUSTRATIVE   CASr-S  OF   ENDOSCOPY    FOR   1-OREIC.N    BODIES. 


Fig.  i86. — Radiograph  sliowing  gold  locket  in  esophagus  of  a  girl  of  2;/^  years. 
Locket  removed  hy  esophagoscopy  witliout  anestliesia.  (Radiograph  by  Dr.  George 
W.  Grier.) 


ILI.USTKATIVl'    CASKS  OF  ENDOSCOPY    FOR   FOREIGN'   BODIES. 


417 


Fic.  387. — kadiiigrapli  showing  artihcial  dciitiirf  in  tlie  esophagus  of  a  man 
aged  thirty  years  Removed  'ly  t sophagoscopy  under  ether  anesthesia.  (Radio- 
grapli  hy  Dr.  Russell  H.  I'.oirgs.     Author's  case.) 


418 


ILLUSTRATIVE   CASES  OF  ENDOSCOPY   EQR   FOREIGN    BODIES. 


Fig  387a. — Button  with  projecting  rigid  pin  in  the  esophagus  of  an  infant  of 
2'/2  months.  Removed  hy  esophagoscopy  without  anesthesia.  Laceration  of  esopli- 
agus  prevented  hy  the  method  iUustrated  in  Fig.  209  (Author's  case.) 


II.LrSTKAIIVE   CASES  OF   ENDOSCOPY    1-OK    l-ilKKICN    i;iil)li;s. 


41!) 


f 


k 


Fui.  .^87!). — Kadiiii^rapiis  slio\»  iiii;  a  dental  roul-caiial  liruach  in  a  small  pos- 
terior branch  of  a  larger  posterior  branch  of  the  inferior-lobe  bronchus  of  a  man 
of  ^g  years.  The  foreign  body  is  seen  just  above  the  dome  of  the  diaphragm  in 
the  anteroposterior  radiograph,  though  really  in  the  part  of  the  lung  down  back  ot 
the  dome  as  shown  in  the  lateral  radiograph.  Removed  through  the  mouth  by 
bronchoscopy  under  local  anesthesia.  This  is  the  lowest  position  from  which  a 
foreign  body  has  ever  been  removed  by  brimchoscopy.  The  full  length  of  a  40  cm. 
bronchoscope  was  barely  sufficient  to  reach  it  ( .Author's  case.) 


CHAPTER     XXII. 

Benign  Growths  in  the  Larynx. 

The  general  subject  is  covered  so  thoroughly  in  books  upon  the 
larynx  that  extensive  consideration  here  would  be  out  of  place.  Only 
some  phases  of  the  subject  which  ha\e  a  particular  bearing  <in  endoscopic 
surgery  will  be  considered.  The  endoscopic  appearances  are  similar  to 
those  by  the  indirect  method  except  as  modified  bv  the  point  of  view  as 
explained  in  Chapter  \'II.  In  all  ailults  careful  clinical  study  by  the  in- 
direct method  should  precede  direct  laryngoscopy. 

Graiiiiloiiiata  in  the  larynx,  while  not  true  neojilasms,  in  some  in- 
stances need  to  be  dealt  with  as  such,  by  extirpation. 

Vocal  nodules,  while  not  true  neoplasms,  arc  occasionally  so  stub- 
bornly resistant  of  other  methods  of  cure  that  surgical  measures  are 
needed.  When  ver\-  ])rominent  thev  may  be  excised  under  local  anes- 
thesia. Should  cocaine  cause  so  much  shrinkage  as  to  make  accurate  ex- 
cision impossible,  general  anesthesia  will  be  required.  The  author  has 
had  excellent  results  in  the  treatment  of  sessile  vocal  nodules  by  touch- 
ing them  with  a  fine  galvano-cautery  point  as  recommended  by  Wylie. 
Sir  St.  Clair  Thomson  favors  this  method  in  exceiJtional  cases,  but  points 
out  that  extreme  dexterity  is  rec|uisite,  a  caution  that  is  particularly  force- 
ful as  we  are,  in  most  instances,  dealing  with  a  patient  to  whom  the 
voice  is  a  valuable  asset.  A  form  of  vocal  nodule  seen  in  children  and 
known  as  "screamers  nodes"  (Dan  McKenzie)  may  be  excised  as  ad- 
vised by  .\lbrecht  (  Ilib.  1  I  ).  Fibromata,  while  possibly  of  infiamniatury 
genesis  in  some  instances,  are  clinically  true  neoplasms,  .^s  a  rule  di- 
rect excision  is  not  followed  l)y  recurrence  if  a  goodU-  portion  of  basal 
tissue  is  removed.  A  typical  case  of  small  fibroma  is  illustrated  in  Fig. 
79.  They  are,  as  a  rule,  best  dealt  with  by  the  tissue  forceps.  Fig.  35. 
They  may  be  sliced  off  with  the  Katzenstein  guillotine  but  the  author's 
personal  preference  is  the  tissue  forceps  mentioned  because  any  desired 
])ortion  of  the  normal  base  can  be  included  in  the  excision.     .\t  times  a 


nKNic.N  '.•.uovvriis  i.n  Tin-;  larynx.  421 

small  granuloma  may  aiJjJear  as  the  healing  granulations  organize  and 
mav  persist  for  a  few  weeks  or  even  months,  simulating  recurrence.  So 
long  as  it  does  not  increase  in  size,  excision  is  not  necessary.  \  ery  large 
fibromata  may  be  e.xciscd  with  the  basket  punch  forceps.  Fig.  :5(;.  If  so 
large  that  the  base  cannot  l)e  seen  they  may  be  amputated  with  the  snare 
(Fig.  -11),  and  then  the  base  may  be  cauterized  galvanically.  or  as  the 
author  prefers,  excised  with  forceps.  The  galvano-cautery  is  especially 
useful  in  destroying  the  basal  vessels  of  fibro-angiomata.  John  A. 
Thompson  (Bib.  .547)  reports  an  interesting  case  of  removal  of  fibroma 
1x1  J4  inches  (2.")x:52  mm.)  in  size,  springing  from  the  upper  orifice  of 
the  larynx. 

The  depth  of  removal  of  benign  growths  is  closely  connected  with 
the  tendency  to  recurrence  of  the  particular  growth,  and  some  informa- 
tion as  to  this  tendency  is  obtainable  from  general  laryngeal  literature. 
Benign  growths  repullulale  on  the  surface  and  do  not  infiltrate.  There- 
fore, a  less  amount  of  normal  is  needed  than  in  malignancy.  Cystomata 
have  'icen  known  to  get  well  after  galvano-puncture  or  excision  of  part 
of  the  sac.  In  the  author's  experience  recurrence  can  be  avoided  with 
certainty  only  by  complete  extirpation  of  the  sac.  The  same  is  true  of 
adenomata.  Angiomata,  which  are  usually  much  more  extensive  and 
deeper  seated  than  appears,  reciuire  deep  excision,  and  the  galvano-cau- 
terv  to  destroy  the  vessels  at  the  base,  both  to  arrest  hemorrhage  and 
lessen  the  tendency  to  recurrence.  A  diiTuse  telangiectasis  if  requiring 
treatment  may  be  ])unctured  or  scarified  at  a  number  of  sittings  with  the 
galvano-cautery.  Lymphoma,  enchomlroma  and  osteoma,  if  small,  may 
be  excised  with  the  basket  ])unch  forceps  (Fig.  31!),  taking  as  much  of 
normal  base  as  ])ossible  without  risk  of  stenosis.  Myxomata,  other  than 
myxomatous  degeneration  of  fibromata  is  very  rare  and  there  are  no 
data  on  which  to  base  a  rule  as  to  depth  of  excision  necessary  to  prevent 
recurrence,  Lipomata  are  also  very  rare.  .An  interesting  resume  of  the 
subject  will  be  found  in  the  article  by  (loldstein  (Bib.  171  ).  iMoni  the  re- 
search there  reported  it  is  clear  that  to  avoid  recurrence  it  is  necessary 
to  remove  thoroughly  every  vestige  of  the  growth.  Thyroid  gland  tu- 
mors from  aberrant  islands  of  thyroid  tissue  do  not  reipiire  very  radical 
excision  of  normal  base  but  should  be  removed  as  completely  as  pos- 
sible. An  excellent  article  is  published  by  Wells  (  I'ib.  .")Sii).  The  fpies- 
tion  of  the  advisability  of  merely  slicing  olT  small  benign  tumors  on  the 
vocal  cords  or  in  the  neighborhood  of  the  arytenoid  joint,  and  deferring 
more  radical  removal  of  the  base  until  the  growth  demonstrates  a  tend- 
ency to  recurrence  is  discussed  under  iia])illoma.  The  technic  of  direct 
removal  of  benign  growths  will  be  found  in  Chapter  \'ll  and  special  at- 
tention  is  called  tr)  ibe  author's  method  of  operating  at  the  side  of  the 


423  HHNir.N    GROWTHS    IN    THE    LARYNX. 

tongue  instead  ;if  o\er  the  doi>nm.  Attention  is  also  cal'ed  tn  the  recent 
development  of  suspension  laryngoscopy,  the  details  of  which,  I'rof 
Killian,  the  originator,  has  honored  us  all  by  describing  in  a  separate 
Chapter  (VIII).  Lynch  has  devised  some  excellent  instruments  for 
suspension  work.  As  stated  by  Sir  St.  Clair  Thomson  (Bib.  539)  external 
operation  is  unheard  of  in  the  treatment  of  simple  laryngeal  neoplasms 
in  adults  and  should  be  resorted  to  only  when  an  expert  has  failed  /rr 
riiis  iiaturales. 

r.\I'II,LUXI.\TA   C)l*  THlv    L.\RYNX    IN    CHILDRF.N. 

Of  all  benign  growths  in  the  larynx  papilloma  is  the  most  frei|uent. 
It  may  occur  at  any  age  of  childhood  and  may  even  be  congenital.  The 
author  has  seen  one  case  in  which  it  was  undoubtedly  congenital  and  one 
in  which  it  was  probably  so.     Both  cases  follow : 

Congenital  papilloma  of  the  larynx.  A  male  infant,  two  months 
of  age  had  had  a  croupy  cr)-  and  stridor  without  cyanosis  since  l>irth. 
It  suddenly  developed  a  marked  increase  in  the  stridor,  with  dyspnea 
and  cyanosis.  The  autb.or  was  called,  but  the  child  was  dead  when  he 
arrived.  Post  mortem  examination  showed  a  paiulloma  on  the  left  cord 
near  the  anterior  commissure.  It  did  not  seem  sufficiently  large  to  ac- 
count for  death  b\-  obstruction  even  allowing  for  shrinkage,  though  the 
symptoms  as  described  by  the  parents  denoted  obstructive  dyspnea.  The 
thymus  and  other  viscera  were  normal.  Doubtless  indrawing  of  the 
upper  laryngeal  aperture  contributed ;  possibly  spasm  did  also. 

In  the  second  case  the  author  was  called  for  direct  examination  of  a 
new  born  male  infant  that  was  cyanotic  and  showed  deep  indrawing  at 
the  supraclavicular  and  suprasternal  notches.  Direct  laryngoscopy,  with- 
out anesthesia,  revealed  a  large  papilloma  occupying  almost  the  entire 
upper  laryngeal  orifice.  It  was  immediately  excised  and  then  the  origin 
was  seen  to  be  single  on  the  right  cord  near  the  anterior  commissure. 
The  patient  was  about  si.x  hours  old  at  the  time  of  operati(jn.  It  was 
seen  once  subsequently  (by  Dr.  L.  C.  Manchester)  about  three  months 
after  operation.  There  was  then  no  sign  of  recurrence,  but  this  is  not 
certain  evidence  that  recurrence  did  not  lake  place  later. 

Methods  of  treatment  of  papillomatu  of  children.  A  sharp  distinc- 
tion must  be  made  between  papillomata  of  adults  and  of  children  because 
of  the  greater  difficulty  in  curing  the  tendency  to  recurrence  in  the  latter. 
In  dealing  with  i)apillomata  of  the  larynx  in  children,  it  is  well  to  re- 
member that  we  have  two  classes  of  case.  Those  in  which  the  growth 
gets  well  either  si)ontaneously  or  with  slight  treatment,  surgical  or  other- 
wise.     Second,   those   which   are   not   readilv   amenal:)le   to   anv   form   of 


BKNIGX    C.KdWTIIS    IN    THE    LARYNX.  423 

treatment  and  require  persistent  treatment  of  recurrences.  Sweeping 
deductions  should  not  be  made  from  reports  of  isolated  cases,  even  if 
observed  for  a  year  after  o;)eration,  because  of  the  different  behavior  of 
difTcrent  cases  as  to  recurrence,  and  cases  reported  immediately  after 
operation  are  valueless  statistically  because  of  the  large  percentage  of  re- 
currences. If  we  are  ever  to  arrive  at  final  conclusions,  all  the  cases 
seen  by  each  observer  must  be  reported,  and  the  report  should  not  be 
made  until  after  at  least  one  year's  observation  of  cure. 

There  are  nine  methods  i<\  treatment  to  Ijc  considered. 

1.  Endolaryngeal  applications. 

2.  Tracheotomy  with  subscc|uent  rest  of  the  larynx  for  a  period 
of  years. 

3.  Thyrotomy  with  radical  extirpation  of  the  growth. 

4.  Fulguration. 

"i.  Radium  and  mesolhurium. 

6.  Roentgen  radiotherapy. 

7.  Endolaryngeal  operation. 

8.  A  comljinatinn  of  two  or  more  of  the  above  mentioned  methods. 

9.  Laryngostomy. 

Delavan  established  the  value  of  alcohol  applications  in  some  cases. 
It  is  usually  best  to  start  with  dilute  alcohol,  say  about  50  per  cent  and 
increase  the  strenglii  until  absolute  alcohol  can  be  used.  The  applications 
may  be  made  by  the  indirect  method,  using  the  gauze  sponges  and  sponge 
holder.  Figs.  2.")  and  2(>.  No  anesthetic  is  needed.  The  sponges  should 
not  be  dri[)ping.  Spasm  usually  subsides  quickly  but  this  or  any  other 
method  should  not  be  used  without  previous  tracheotomy  if  there  is 
stenosis.  E.  I..  Jones  has  had  excellent  results  from  organic  salicylic 
acid  saturated  solution  in  alcohol. 

Tracheotomy  for  papUltniuita.  The  beneficial  effect  of  tracheolotny 
has  long  been  noted.  It  is  \ery  marked  in  some  cases,  disap[)ointing  in 
others.  Ai)art  from  its  beneficial  effect  it  should  always  be  done  as  soon 
as  the  child  develops  noisy  breathing  and  restlessness  at  night.  Severe 
dyspnea  with  indrawing  of  the  supraclavicular  and  sternal  fossae  and 
epigastrium  should  not  be  awaited.  The  rule  should  be,  here  as  else- 
where, to  do  the  tracheotomy  always  early  rather  than  late.  Many  cases 
are  in  extremis  when  they  arrive.  Hallenger  reports  the  death  of  a  child 
with  pai)illoma  of  the  larynx  on  the  way  to  the  hospital,  and  a  similar 
experience  is  known  to  almost  every  laryngologist.  In  cases  of  i)apillo- 
mata  of  large  size,  completely,  or  almost  completely,  obstructing  the 
lumen  of  the  trachea,  it  is  necessary  to  proceed  with  extreme  caution  with 
the  direct  laryngoscopy,  and  not  to  unduly  prolong  the  examination,  be- 


424  BENIGN    C.KOWTIIS    IN    THE    LARYNX. 

cause  engorgement  of  the  papillomata  may  very  much  increase  their  size 
and  obhterate  what  little  lumen  remains.  It  takes  but  a  moment,  with- 
out any  anesthesia,  to  get  a  good  view  of  the  larynx ;  but  failing  in  this, 
the  operator  who  suspects  papilloma  in  any  extremely  dyspneic  case,  is 
perfectly  justified  in  doing  the  tracheotomy  first  and  making  the  diagnosis 
as  to  the  exact  condition  afterward.  The  state  of  affairs  in  regard  to 
tracheotomy  for  dyspnea  is  precisely  the  same  as  gastrostomy  for  dys- 
phagia. 

Thyrotomy  for  papilloiuata.  I'.efore  the  days  of  direct  laryngos- 
copy the  author  tried  thyrotomy  for  the  removal  of  papillomata  in  chil- 
dren. The  recurrence  was  so  prompt  that  the  author  abandoned  thyrot- 
omy for  this  purpose  and  has  rejieatcdlv  spoken  against  it.  He  is  de- 
lighted to  find  that  his  opinion  in  this  respect  coincides  with  that  of  the 
greatest  living  authority  on  the  larynx.  Sir  Felix  Semon,  who  mentions 
one  case  (Bib.  511)  in  which  seventeen  thyrotomies  were  performed  on 
the  same  patient  with  failure  to  cure.  A  great  deal  of  damage  may  be 
done  to  the  larynx  by  repeated  thyrotomies.  and  intractable  stenosis  from 
deformity  is  almost  certain  to  result.  In  these  days  of  quick  and  thor- 
ough removal  by  direct  laryngoscopy,  there  is  rarely  justification  for  doing 
thyrotomy,  because  endoscopic  removal  is  just  as  thorough,  no  more  likely 
to  be  followed  by  recurrence  and  repeated  endolaryngeal  removals  are 
harmless  if  carefully  done. 

fiilguration  for  papillomata.  Harmon  Smith  (  ISib.  470)  has  had 
very  satisfactory  results  with  fulguration  for  papillomata  in  children  and 
his  interesting  article  should  be  read  for  details  of  the  technic. 

Radium  for  papillomata.  Thomas  J.  Harris  (Bib.  Iil4 )  reports 
very  favorable  results  from  the  use  of  radium  in  one  case  of  his  own 
and  in  twelve  cases  in  the  hands  of  Abbe.  Culbert.  Freudenthal,  Polyak, 
Ivillian   and    Alazzochi.  As   stated   bv    tlarris,    imi   mgm.   of    radium 

should  be  applied.  \\  eaker  applications  probablv  irritate,  ihe  duration 
of  each  application,  of  course.  de]iends  upon  the  quantity  of  radium  in 
the  container.  \\  ith  loo  mgm.  of  radium  element,  or  its  equivalent  in 
liromide  or  other  salt,  a  duration  of  20  minutes  is  probably  sufficient. 
From  two  to  ten  sittings  are  usually  necessary.  .A  single  application  in 
some  instances  has  caused  a  marked  diminution  in  the  growth,  but  recur- 
rences, as  with  other  methods,  will  probably  require  repeated  treatments. 
Some  cases  do  not  seem  to  yield  so  readily.  The  future  will  determine 
the  exact  sphere  of  usefulness,  and  the  dosage  and  duration  of  applica- 
tions. A  screening  of  not  less  than  two  mm.  of  metal  and  outside  of 
the  metal  two  mm.  of  hard  rubber  are  essential  to  protect  healthy  tis- 
sues. The  radium  container  should  have  an  eve  bv  means  of  which 
it  can  be  secured  in  position  hv  attaching  it  to  the  tracheotomic  cannula 


BKNICN    C.KOWI'H;.    IN    TIIK    T.AKYXX.  i2'> 

above  which  it  is  inserted.  The  capsule  may  be  hekl  in  place  in  un- 
tracheotomized  cases,  but  the  spasm  excited  rec|uires  a  small  container 
with  suHicient  screenintj  and  dosage.  Mesothdiium  has  been  used  by 
Killian. 

Endolaryuiical  extirpation  of  papUlomata  in  children  is  practically 
limited  to  the  direct  method.  Xo  one  who  has  ever  worked  by  the  direct 
method  would  think  of  i^oing  back  to  any  indirect  attempt  in  children, 
necessitating  as  it  usually  does,  general  anesthesia.  To  work  with  the 
mirror  in  an  adult  under  local  anesthesia  is  difficult  enough,  but  to  work 
with  a  child  under  a  general  anesthesia  with  the  mirror  presents  diffi- 
culties that  are  almost  insurmountable,  to  say  nothing  of  the  extreme 
danger  of  anesthesia  in  this  class  of  cases.  Worse  yet  is.  as  was  done  in 
the  old  days,  a  finger-guided  forceps  operation.  As  elsewhere  stated 
no  anesthetic  whatever,  general  or  local,  is  needed  in  the  extirpation  of 
papillomata  in  children.  If.  for  any  reason,  a  general  anesthetic  is  used. 
it  should  be  only  in  the  tracheotomized  cases  because  of  the  danger  in 
dyspnea  in  untracheotomized  patients.  If  a  general  anesthetic  be  used 
it  is  absolutely  needless  to  add  th.e  risk  of  a  cocaine  application  in  a 
child.  As  a  matter  of  fact  a  general  anesthetic  has  only  one  excuse,  and 
that  is  to  lessen  the  spasm  of  the  larynx  in  order  to  enable  the  operator 
more  accuratelv  to  ajijfly  his  forceps.  With  increased  practice  the  oper- 
ator will  find  that  even  for  this  purpose  it  is  unnecessary.  There  is  a 
peculiar  sensation  of  softness  to  papillomata  that,  once  recognized,  is  un- 
mistakable and  that  w  ill  prevent  the  operator  from  forcibly  removing  any 
tissue  other  than  papillomatous  because  of  the  firm  resistance  felt  when 
normal  tissue  is  grasjied.  In  other  words,  the  operator  must  train  him- 
self to  apply  just  the  amonm  uf  |>ressure  to  his  forceps  which  is  neces- 
sary to  remove  papillomatous  tissue,  but  which  will  not  bile  into  normal 
tissue.  It  goes  without  saying  that  such  a  degree  of  tactile  sensibility 
can  only  be  possible  with  extremely  delicate  and  easy  working  forceps. 
Heavy  handled,  spring  opposed,  clumsy  instruments  will  bite  out  any- 
thing, even  cartilage,  before  any  useful  sensation  is  communicated  to 
even  the  most  delicate  touch,  because  delicacy  is  destroyed  by  the  op])o- 
sition  of  the  spring  and  the  crude  mechanism.  Some  authors  advise 
against  removal  of  pai)illomata  in  children  during  the  stage  of  growth, 
])rcferring  to  do  a  tracheotomy  and  wait  for  a  ])eriod  of  recession  of  the 
growth  before  extirpation.  The  dilliculty  is,  as  Sluckv  puiiUs  niu.  in 
determining  tlie  period  of  recession.  1 'apilloniala  should  always  be  re- 
moved and  the  patient  cured  of  recurrences,  because,  contrary  to  state- 
ments sometimes  made,  a  child  is  not  safe  with  only  a  tracheotomy  can- 
nula U|]on  which  to  depend  for  air.  unless  under  constant  care  of  a  phy- 
sician and   an   experienced  tracheal   luirse.     Accidental   removal   of   the 


42(<  BKNIGN    GROWTHS    IN"    THE    LARYNX. 

cannula  following  indrawing  closure  of  the  fistula  has  caused  the  death 
of  many  children.  Others  have  died  of  occlusion  of  the  cannula  with 
secretions,  dressings,  granulations  and  papillomatous  masses.  In  all 
cases  of  papilloma  of  the  larynx  the  subglottic  trachea  should  be  in- 
spected not  only  once  but  at  e\ery  removal  of  the  supraglottic  papillo- 
mata.  Many  endoscopists  have  wondered  why  they  cannot  decannulate 
a  papilloma  case  after  removal  of  apparently  all  the  growth.  The  rea- 
son is  that  the  region  between  the  glottis  and  the  tracheal  wound  is  full 
of  papillomata.  For  this  removal  a  bronchoscope  may  be  inserted  through 
the  glottis,  or  a  bronchoscope  not  slanted  at  the  end  ma}-  be  used  for 
supraglottic  tracheoscopy.  The  author  uses  the  direct  laryngoscope  and 
the  tissue  forceps,  Fig.  oT).  In  some  cases  the  tracheal  papillomata  can 
be  removed  through  the  tracheal  wound.  Often  it  is  impossible  to  dis- 
tinguish between  granulation  tissue  and  true  papillomata  except  by 
biopsy.  It  is  not  necessary,  however,  clinically  to  distinguish  as  it  is  a 
good  thing  to  remove  granulations  which  are  so  exuberant  as  to  simulate 
papillomata.  The  technic  of  direct  laryngeal  extirpation  is  considered 
in  Chapters  \'II  and  \'III.  The  special  infant-size  slide  speculum  is  best 
for  infants  under  6  months. 

The  antlior's  method  for  papillomata  in  children.  The  author  has 
had  best  results  from  a  combination  of  the  alcohol  application  of  Dela- 
van  between  excisions  by  the  direct  method,  and  with  tracheotomy  in  all 
cases  that  persistently  repullulate.  No  tracheotomy  is  done  at  first,  if  the 
growth  is  small  and  especially  if  single  (they  rarely  are),  because  there 
is  a  chance  of  cure  by  a  few  extirpations  or  in  a  few  instances  even  by  a 
single  extirpation.  If  the  child  is  slightly  dyspneic  the  obstructing  part 
of  the  growth  is  first  removed  directly  without  anesthesia,  general  or 
local,  and  then  the  remaining  fungations  are  extirpated  at  a  number  of 
brief  seances.  The  alcohol  applications  are  not  used  in  these  cases. 
When  repullations  and  growths  in  new  locations  demonstrate  an  in- 
tractable case,  it  is  treated  the  same  as  a  dyspneic  case.  If  the  child  is 
very  dyspneic  when  first  seen  the  author  does  a  tracheotomy,  waits  a 
week  or  ten  days,  and  then  proceeds  with  the  extirpation  without  anes- 
thesia and  the  alcohol  after-treatment.  The  child  is  kept  in  the  hospital 
under  the  watchful  care  of  special  tracheal  nurses.  If  the  growths  are 
subglottic,  reactionary  edema  of  this  region  is  very  apt  to  rec|uire  tracheot- 
omy after  extirpation,  and  therefore  subglottic  cases,  whether  dyspneic 
or  not,  are  tracheotomized  unless  the  growth  is  single  and  very  small. 
The  effect  of  the  alcohol  and  the  stiperficial  cicatrices  is  to  make  an  un- 
favorable soil  for  the  growth  of  papillomata  which,  in  a  sense,  resemble 
\enereal  warts.  CiaKano-cauterization  is  used  in  the  worst  cases  to  de- 
stroy the  bases  and  to  promote  superficial  cicatrices.    The  eflicacy  of  re- 


UKNIGX    C.KnWiIlS    IX    THE    LARVXX.  427 

moval  and  the  post  oi)erative  jqjplication  of  alcohol  has  been  corroborated 
by  Stucky  (Bib.  ■'Al)  and  a  number  of  other  laryngologists.  Its  great- 
est drawback  is  the  length  of  time  rec|uirc(l  for  cure  in  the  very  stubborn 
cases.  But  it  will  eventually  cure  almost  all  cases,  and  as  the  extirpations 
without  anesthesia  are  not  painful  t  the  children  do  not  even  cry  after  the 
tirst  few  treatments)  the  author  feels  justified  in  adhering  to  it  uniil 
some  equally  effective  and  more  rapid  method  is  sufficiently  tested. 

Lar\nuostomy.  When  all  else  fails  in  the  few  most  stubborn  cases, 
laryngostoniy  m.ay  be  reported  to.  Lining  the  larynx  with  ejiidermal 
epithelium  makes  a  soil  upon  which  papillomata  will  not  grow,  notwith- 
standing the  fact  that,  as  occurred  in  one  case  of  the  author,  a  t\pical 
pa[)illoma  identical  liistologicallv  with  the  laryngeal  growths  occurred  on 
the  normal  skin  of  the  neck  The  after-treatment  of  laryngostoniy  ex- 
tends over  months,  l/nlike  thyrotomy,  it  does  not  produce  stenosis  by 
causing  deformitv  of  the  larynx.  Cases  stenosed  by  injudicious  thyrotomy 
are  curable  by  laryngostomy,  which  are  the  only  papillomatous  cases  in 
which  the  author  advises  laryngostomy. 

l'.\l'II.l.OM.\T.\  IX  THE  L.\RVXX  OF  .\DULTS. 

Papillomata  in  adults  are,  on  the  whole,  much  more  amenable  to 
treatment  than  similar  growths  in  children.  Tracheotomy  is  very  rarely 
re(|uired.  and  recurrences  are  slower  in  development.  Many  more  cases 
are  cured  by  a  single  extir[>ation  and  recurrences  at  new  sites  are  not  so 
conmion.  In  some  instances  the  growths  may  be  single,  relatively  quite 
librcius  and  pechmculatcd.  This  form  is  beautifully  illustrated  in  an  in- 
teresting article  by  Loeb  (Bib.  •'STSj. 

In  all  forms  of  papillf)mata  in  adidls  operative  remoxal  is  so  satis- 
factory that  tlu-re  is  little  temptation  to  try  other  methods. 

Pcf^th  of  removal  of  popUlomata.  Should  the  growth  be  simply  re- 
moved from  the  surface?  ( )r  should  the  basic  normal  be  removed?  And 
if  so,  how  widely?  To  determine  this  point  clinically,  it  was  necessary 
to  know  whether  the  reapi)earances  of  papillomata  are  repullulations  at 
the  site  of  removal  or  whether  fresh  areas  became  the  site  of  new  growths. 
To  determine  this  i>oint  accurate  drawings  were  made  by  the  author,  and 
it  was  discovered  that  in  eighteen  cases  nin  of  twenty  there  was  no  re- 
currence at  the  site  of  removal  if  about  ;!  millimeters  depth  of  nor- 
mal tissue  was  removed.  That  is,  there  was  no  recurrence  in  the  scar. 
In  iwo  cases  the  recurrence  was  so  close  as  to  be  doubtful.  On  the 
nlher  hand,  in  this  same  series  of  twenty  cases  in  locations  where  the 
growths  were  sinijily  removed  from  the  surface,  twenty  out  of  twenty 
instances  recurred.  In  another  series  of  eighteen  cases  in  which  surface 
remn\al  was  done,  papillomata  ap|)eared  in  a  greater  number  of  new  lo- 


428  F.KNir.X    GROWTHS    IN    THK    I.Ai;Y.\X. 

cations  after  operation.  It  still  remains  a  question  whether  the  less  tend- 
enc}'  to  recurrence  after  removal  with  a  normal  base  was  due  to  extir- 
pation of  every  vestige  of  growth,  or  whether  it  was  simply  due  to  the 
fact  that  scar  tissue  is  a  bad  soil  for  papillomatous  growth.  Clinical  ob- 
servation shows  that  papillomatous  growths  in  the  larynx  or  trachea 
usually  do  not  spring  from  a  tirm  thick  scar.  The  author  has  noted  the 
avoidance  of  scars  by  papillomata  when  extending  down  the  trachea 
from  the  larynx  toward  the  tracheotomic  wound.  In  the  author's  opinion, 
when  the  growths  are  situated  on  the  cords  it  is  usually  better  to  re- 
move them  with  a  very  scanty  base,  telling  the  patient  of  I'robable  re- 
currence. If  there  is  a  recurrence,  slightly  more  radical  remo\al  is  in- 
dicated, but  under  no  circumstances  should  reckless  or  radical  extirpa- 
tion of  normal  tissue  be  indulged  in.  Cicatricial  stenosis  and  prolonged, 
possibly  permanent,  impairment  of  the  voice  may  result.  In  case  of  re- 
movals in  the  neighborhood  of  the  arytenoids,  great  care  must  be  used 
to  avoid  impairment  of  the  laryngeal  motility.  The  growths  should 
everywhere  be  nipped  off  with  only  a  small  normal  base  and  recurrences 
should  be  similarly  nipped  in  the  bud.  Alcohol  applications  are  useful. 
In  contrast  with  the  prompt  and  excellent  results  obtained  in  most  cases, 
a  very  stubborn  case  is  occasionallv  encountered  which  simulates  the 
conditions  found  in  children.     The  following  is  an  example : 

A  single  woman,  aged  twenty-five,  was  sent  to  the  author  by  Dr.  I. 
I!.  Reed  for  loss  of  voice  of  three  months'  duration  following  two  months 
of  hoarseness.  Within  the  last  two  weeks  dysjinea  had  been  developing 
and  examination  by  the  indirect  method  re\ealed  a  large  mass  of  papil- 
loma occupving  the  entire  right  half  of  the  larynx  with  more  masses  on 
the  epiglottis  and  high  up  on  the  left  ventricular  band  (A.  Fig.  7I>)- 
These  were  remoxed  giving  complete  relief  from  the  dyspnea  and  permit- 
ting some  phonation.  The  patient  was  not  seen  for  some  time  and  re- 
turned extremely  dyspneic.  A  recurrence  of  larger  size  than  the  original 
growth  was  foimd  and  many  new  locations  were  invaded,  .\fter  remov- 
ing the  upper  growth  it  was  found  that  the  pa])illomata  had  sjirung  up  in 
the  trachea  which  at  the  first  operation  was  entirely  free.  I'atient  work 
and  many  sittings  were  necessary  until  finally  at  the  end  of  sixteen 
months  the  patient  was  entirely  free  from  any  sign  of  recurrence  and  has 
remained  so  since.  A  period  of  four  years  having  now  elapsed,  the  i'a- 
tient may  be  called  cured.  The  vocal  results  are  excellent,  the  patient's 
voice  perfectly  normal  for  speaking  and  quite  a  good  singing  voice  has 
also  returned.  This  the  author  regards  as  due  to  the  careful  avoidance 
of  injury  to  any  of  the  submucosal  tissues.  .Vecessarilj-  a  considerable 
amount  of  the  mucosa  itself  was  removed  with  the  base  of  the  papilloma. 


HKNIGN'  CKowi'iis  IN  'riii:  i.akvnx.  42it 

Plastic  opciation  favoriiui  the  dciclopmcnt  at  adventitious  vocai 
hands.  Some  of  the  cases  of  papillomata  from  frc(|uent  accidents  asso- 
ciated with  iinHrect  operations  come  in  with  the  cords  entirely  destroyed 
and  the  larynx  badly  damaged.  If  there  is  motility  in  the  arytenoids  there 
is  good  hope  of  repair  by  careful  work.  The  following  case  is  an  ex- 
amiiie  : 

A  man,  aged  twent\-five.  had  been  under  the  care  of  one  of  the  old- 
est laryngologists  in  the  country  for  two  and  one-half  years  for  hoarse- 
ness. During  this  time  a  number  of  indirect  operations  upon  the  larynx 
had  been  done  for  renio\al  of  papillomata.  The  operations  were  difficult 
because  the  patient  was  insusceptible  to  anesthesia  In-  cocaine,     lie  was 


Fig  .388. — IllustraliiiK  operation  favoring  formaiion  of  an  ailvi-ntitious  vocal 
band  in  a  man  aged  twcnt.v-five  ycar.s.  .A.  Papilloma  and  Kranulation  tissue  with 
destruction  of  the  vocal  cords  and  the  lip  of  one  arytenoid  eminence  as  the  result 
of  indirect  operation.  B.  Cured  of  papilloma  after  many  direct  extirpations  under 
local  anesthesia.  A  web  extended  across  the  larynx  from  the  right  side  from  the 
neighborhood  of  the  site  of  the  original  cord  to  the  remnant  of  the  ventricular 
band  of  the  left  side.  Dotted  line  sliows  the  position  of  incision  for  a  plastic  to 
assist  in  forming  an  adventitious  band  on  the  left  side.  C.  Three  months  later 
the  triangular  mass  of  cicatricial  tissue  shown  in  11  has  become  stretched  out  into 
an  adventitious  band.  0.  Three  months  later  entire  stretching  out,  absorption 
and  disappearance  of  the  elevation,  resiillinir  in  the  normal  larynx  \\ith  good  voice. 
From  a  crayon  drawing  by  the  autlior.  Patient  referred  to  llie  author  by  Dr. 
JaiT;es  F.  McKernon. 

c()ni])letcly  aphonic  and  could  mil.  with  the  most  vinlcnt  ellorts,  phonate 
in  the  slightest  degree.  In  this  condition  be  a|)plied  to  Dr.  James  1". 
McKernon  of  Xcw  \'ork  City  who  found  the  larynx  filled  with  a  mix- 
ture of  papillomatous  and  granulation  tissue.  Xo  sign  of  a  cord  was 
present  (A,  Fig.  :!S,S).  Part  of  the  arytenoid  eminence  was  gone  and  its 
place  was  taken  iiy  a  fungating  luass  of  granulation.  A  i)art  of  each 
ventricular  band  was  gone  and.  granulations  covered  both  bands.  On  at- 
tempted i)honation  jjoth  arytenoids  moved,  but  no  sign  of  aiivthing  re- 
sembling a  vocal  cord  resultecl  finni  the  movement.  Dr.  McKernon  re- 
ferred the  case  at  once  to  the  author  for  treatment.  Lnder  local  anes- 
thesia, the  author  removed  all  the  tissues  that  looked  pai)illomatous  and 


4:30  BKNir.N    C.ROWTHS    IN    'J' 1 1 1-    LAkVNX. 

some  of  the  most  exuberant  granulations.  At  intervals  during  the  fol- 
lowing year  recurrences  of  papillomata  were  removed,  until  at  the  end 
of  sixteen  months  the  patient  returned  after  a  three  months'  interval 
completely  free  from  granulation  and  recurrences.  A  web  extended 
across  the  larynx  oljliterating  the  entire  anterior  half  as  shown  at  B, 
Fig.  388.  The  author  then  did  a  plastic  operation  by  making  an  incision 
along  the  dotted  line  marking  out  a  cord  from  the  cicatricial  tissue,  the 
incision  extending  from  the  arytenoid  clear  out  to  the  perichondrium  an- 
teriorly. The  tissue  seemed  under  tension  and  the  triangular  flap  after 
the  incision  hung  almost  altogether  over  toward  the  patient's  left  side 
and  away  from  the  adventitious  band  on  the  patient's  right.  The  inci- 
sion was  made  with  the  laryngeal  knife,  Fig.  S-").  At  the  end  of  three 
months  this  flap  had  flattened  out  and  the  action  of  the  arytenoid  on  the 
cicatricial  tissue  had  formed  a  verj-  fair  adventitious  band  with  a  projec- 
tion simulating  a  vocal  nodule  (C).  The  first  impulse  was  to  remove 
this,  but  believing  that  it  would  furnish  tissue  to  be  extended  by  the 
combined  effects  of  cicatricial  contraction  and  the  arytenoid  action  noth- 
ing was  done  with  it.  Three  months  later  the  patient  returned  and  ex- 
amination showed  the  condition  to  be  as  shown  in  1!.  The  patient  at  this 
visit  reported  that  six  weeks  before,  he  had  astonished  himself  and  his 
family  by  speaking.  Dr.  AIcKernon,  who  was  kind  enough  to  again 
examine  the  patient,  in  the  condition  shown  at  D,  stated  that  he  thought 
the  results  quite  a  clear  indication  of  the  possibilities  of  work  by  the  di- 
rect method.  The  patient  is  now  able  to  do  his  part  of  the  shouting  in 
a  football  game.  The  voice  is  deep  and  somewhat  rough  ;  but,  judging 
by  similar  cases,  it  will  become  smoother  in  time. 

For  the  success  of  the  operation  it  is  necessary  to  wait  until  the 
cicatricial  contraction  has  put  the  scar  on  tension,  otherwise  the  incision 
is  apt  to  heal  and  unite  its  two  edges.  On  the  contrary,  if  there  is  ten- 
sion, as  in  this  case,  the  incision  will  gape  so  widely  that  there  will  be  no 
chance  of  its  adhering  and  the  subsequent  cicatricial  contraction  will  tend 
to  widen  the  gap  instead  of  to  narrow  it.  Another  factor  in  the  success 
of  this  kind  of  a  case  is  not  to  remove  tissue  ;  differing  in  this  respect  from 
cases  of  redundancy  such  as  shown  in  Fig.  15,  Plate  I.  The  adventitious 
bands  are  always  thick  at  first  and  become  thinned  down  as  the  cicatricial 
tissue  contracts  and  as  the  effect  of  the  traction  of  the  arytenoid  begins 
to  become  manifest.  The  author  has  used  similar  operations  in  cicatricial 
larynges  following  conditions  other  than  [)apillomata,  though  not  always 
with  the  same  success  as  in  the  case  above  mentioned. 


CHAPTER    XXIII. 

Benign  Growths  Primary  in  the 
Tracheobronchial  Tree. 

Bcn'ujii  f/roictlis  f^riiinirx  in  llir  trachea  and  bronchi.  Extension  of 
papilloniata  from  the  lar)-nx  into  the  cervical  trachea,  especially  about 
the  tracheotomy  wound  is  of  relatively  common  occurrence,  and  that 
form  of  tracheal  benignancy  ban  already  been  considered  in  its  proper 
place,  with  laryngeal  growths.  L'nder  the  present  heading  will  be  in- 
cluded only  the  primary  neoplasms  of  the  tracheo-bronchial  tree.  I'aijil- 
lomata  and  fibromata  are  the  most  fre(|uent  of  the  benign  tumors  in  the 
trachea.  .Aberrant  tlnroid,  lipomata.  enchondromata.  chondrosleomata, 
adenomata  and  lipomata  occur  in  the  trachea,  but  not  all  of  these  have 
been  reported  to  have  been  discovered  endoscopically.  When  the  au- 
thor encountered  the  first  case  of  primary  tracheal  benign  tumor  in  the 
early  days  of  bronchoscopy  (Ijib.  3(19)  he  supposed  that  such  tumors 
were  not  uncommon  but  simply  undiscovered.  In  the  nine  years  that 
have  elapsed  since  that  time  he  has  seen  but  one  other  benign  true  neo- 
plasm in  the  tracheo-bronchial  tree,  though  he  has  seen  a  number  of  be- 
nign "tumors"'  not  truly  neoplastic. 

Papilloma  primary  in  the  trachea.  Mann  reports  two  very  inter- 
esting cases  of  this  kind  diagnosticated  and  removed  bronchoscopically. 
Other  interesting  cases  are  reported  by  von  Schrotter  and  Spiess.  The 
author's  previously  reported  case  is  as  follows: 

A  girl,  aged  four  years,  was  brought  to  the  Eye  and  Ear  Hosi)ital 
Dispensary  for  cough  which  had  persisted  for  two  months  since  "strang- 
ling" on  a  crumb  of  bread  that  "got  down  the  wrong  way.''  Radiograph 
by  Dr.  Russell  H.  lioggs  was  negative.  Physical  examination  by  Dr. 
Brush  demonstrated  a  cooing  sound  all  over  both  sides  of  the  chest. 
There  was  no  dyspnea  or  cyanosis.  Thinking  of  the  possibility  of  a  for- 
eign bodv  in  the  bread,  the  author  passed  a  lironchoscope  and  found  a 
small   ]iinkisli   while   mass  of   tissue  about   six   millimeters   in   diameter. 


432  BENIGN   C.RIJWTIIS  TKLMARV   IX   TRACHKOBRONCHIAL  TRKE. 

with  mammillated  surface  attached  to  the  left  tracheal  wall  about  one 
centimeter  alio\e  the  biftircation.  Thinking  of  a  foreign  body  granu- 
loma, the  author  excised  the  tissue,  leaving  a  flat  surface  oozing  a  trifling 
amount  of  blood,  but  no  sign  of  foreign  body.  Dr.  Joseph  H.  Barach 
reported:  "Histologic  examination  of  the  tissue  shows  a  typical  papil- 
loma which  could  not  be  confused,  histologically,  with  a  granuloma.'' 
The  child  did  not  return  to  the  clinic.  Dr.  L.  C.  Manchester,  who  kindly 
went  to  the  child's  home  to  have  her  brought  back  to  the  clinic,  failed 
to  convince  the  parents  of  the  necessity,  the  cough  having  disappeared. 
When  seen  by  him  a  second  time,  about  three  months  later,  the  cough 
had  not  returned  and  there  was  no  cooing  sound  or  other  abnormality 
ai)parent  to  physical  examination.  The  child  was  lost  to  further  obser- 
vation. 

fibroma  primary  in  the  traclieo-broHchlal  tree.  An  interesting  case 
of  fibroma  is  reported  by  Sauer  (Bib.  .">!.")),  occurring  in  a  man,  aged  7-i 
years.  The  growth  produced  severe  dyspnea  and  was  detached  bv  the  in- 
sertion of  the  bronchoscope  and  was  coughed  up  in  two  i)ieces.  Emil 
Mayer  (Bib.  4iiS)  reports  the  tliscoverv  and  removal  of  a  soft  fibroma 
from  the  bronchus  of  a  child  bronchoscoped  for  bronchiectasis. 

The  author's  case  of  fibroma  is  as  follows:  A  boy  of  Hi  years  was 
referred  to  the  author  by  Dr.  Henry  Eastman  for  cough  which  had  per- 
sisted for  six  weeks  since  inhaling  an  insect  thought  to  have  been  a  fly. 
'I'lie  insect  had  been  coughed  up  and  identified  in  the  sputum  a  few  days 
after  the  accident  but  the  cough  did  not  ameliorate.  Radiographic  ex- 
amination by  Dr.  George  C.  Johnston  and  physical  examination  by  Dr. 
Henry  Eastman  were  both  negati\e.  At  bronchoscopy  under  local 
anesthesia  the  author  found  a  smooth,  pedunculated  and  freely  movable 
growth,  about  six  centimeters  in  diameter  attached  to  the  lower  margin 
of  the  orifice  of  the  left  u])per  lobe  bronchus.  Traction  with  straight 
forceps  demonstrated  a  firm  attachment  which  was  excised  along  with  a 
liberal  amount  of  base  by  the  tissue  forceps  (  P'ig.  3.")).  There  was  lilood 
streaked  expectoration  for  a  few  days.  At  bronchoscopy  two  weeks 
later  there  was  no  sign  of  recurrence.  Dilated  ca[)illaries  were  visible 
in  tlie  neighborhood  of  the  site  of  removal.  Bronchoscopv  aboiu  eight 
months  later  showed  no  sign  of  recurrence  and  the  boy  seemed  normal 
in  every  way.  Histological  examination  by  Dr.  lamest  W.  W'illetts 
showed  the  growth  to  be  a  pure  filiroma  of  probably  slow  formation  and 
long  standing. 

Enchondroma  of  the  traeheo-hronehial  tree.  \'on  Eicken  (  I'.ib.  ."iill  ) 
reports  the  remo\al  of  an  enchondroma  of  the  bn  melius  liy  means  of 
biting  forceps. 


BENIGN   C.ROWTKS   rklMARV   IN   TRACIIKOBRONCHIAL  TRKK.  433 

Amyloid  tumors  of  the  trachea  are  reported  by   Reicli    (  IJih.  4(i3). 

Osteomaia  of  the  trachea  are  re])orted  by  Mackleston  (Hib.  400) 
and  Levinger  (Bib.  3-51). 

r.chinococcus  of  the  lung  in  an  isolated  focus  producing  dyspnea  was 
discovered  bronchoscopically  by  Kob  and  the  case  is  reported  by  \\  ad- 
sack  (Rib.  32.5  and  587). 

Thyroid  tumors.  (Benign).  While  not  a  true  neoplasm,  the  oc- 
currence of  aberrant  thyroid  tissue  within  the  lumen  of  the  trachea  may 
be  so  regarded  and  should  be  so  treated.  The  author  has  had  one  such 
case,  as  follows: 

A  woman  of  34  years  was  certain  that  she  had  aspirated  a  fish  bone 
three  days  before  coming  to  the  author.  Bronchoscopy  revealed  a  tracheo- 
bronchitis. Xo  foreign  body  was  present,  but  a  small  pedunculated 
tumor  was  found  attached  to  the  left  anterior  wall  of  the  trachea.  It 
was  removed  with  the  tissue  forceps.  Fig.  3.3,  and  found  by  Dr.  W'illetts 
to  be  composed  of  thyroid  tissue.  The  endotracheal  wound  healed  in  a 
few  days,  and  eight  months  later  there  was  no  sign  of  any  operation  hav- 
ing been  done  upon  the  trachea  and  the  wall  seemed  smooth  and  normal. 
The  thyroid  gland  and  its  isthmus  were  in  normal  position  and  of  about 
normal  size.  It  seems  quite  unlikely  that  the  tumor  had  any  connection 
whatever  with  the  patient's  symptoms,  though,  as  mignt  nave  been  ex- 
pected, the  symptoms  subsided  and  probably  would  have  done  so  with- 
out operation.  .A  very  interesting  consideration  of  the  thyroid  gland  in 
its  relations  to  the  trachea  has  been  written  by  Otto  Stein  (liib.  r)()2). 

Granuloma  of  the  trachea,  the  result  of  perichondritis,  has  lieen 
observed  by  the  author  in  a  number  of  instances.  In  two  cases  it  was  due 
to  the  traumatism  of  a  foreign  body  aspirated  and  coughed  ui)  three 
weeks  and  two  months  respectively  after  the  accident.  In  the  first  in- 
stance, the  granuloma  was  found  at  bronchoscopy  two  months  after  the 
cougiiing  up  of  the  foreign  body,  and  in  the  second,  about  four  weeks 
after.  In  both  cases  bronchoscopy  was  done  for  persistent  cough  and 
dyspnea,  which  led  to  the  suspicion  that  the  foreign  body  might  have 
been  multiple,  with  consequently  one  or  more  still  remaining  in  the  air 
]iassages.  In  both  instances,  removal  of  the  granulation  tissue  with  aj)- 
plication  of  argyrol  in  3(1  per  cent  solution,  resulted  in  a  cure,  only  one 
treatment  being  necessary  in  one  case  and  three  treatments  in  the  other. 
A  very  interesting  case  of  granuloma  in  the  trachea  is  reported  by  Sir 
Robert  Woods.  Extreme  dyspnea  nn  bnth  inspiration  and  expiration 
had  persisted  for  two  months  after  an  attack  of  bronchitis.  Three  bron- 
choscopic  removals  resulted  in  a  i)erfect  cure.  The  possibility  of  a 
granuloma  being  tuberculous  or  luetic  must  always  be  kept  in  mind. 


434  BENIGN   GROWTHS  PRIMARY  IN   TRACll  I'l  )BR(>NCIIIAL  TREE. 

Symptoms  of  benign  tumors  of  the  trachea.  Whether  or  not  cough 
is  a  usual  symptom  of  tracheo-bronchial  benign  tumors,  it  is  impossible 
to  say,  because  the  small  number  of  cases  reported  form  an  insufficient 
basis  for  deduction,  but  it  seems  the  most  constant  symptom.  Dyspnea 
and  all  of  the  symptoms  of  defective  drainage  of  secretions  supervene 
when  the  growth  becomes  large  enough  to  be  obstructive.  Radiography 
is  of  service  in  enchondromata  and  osteomata,  and  its  routine  use  in  all 
chronic  chest  diseases  is  indicated  from  many  viewpoints.  Doubtless  the 
same  will  be  said  in  the  future  in  regard  to  bronchoscopy. 

Endoscopic  appearances  of  benign  grcn^'tlis.  The  detection  of  be- 
nign growths  endoscopically  is  not  at  all  difficult,  but  occasionally  granu- 
lation tissue  will  be  removed  under  suspicion  of  being  neoplastic.  As 
this  is  good  treatment  anyway  for  exuberant  granulation,  it  is  the  proper 
course  and  the  microscope  can  make  the  diagnosis.  Another  possible 
mistake  is  a  small  adherent  mass  of  secretion  which  sometimes  simulates 
a  white  growth  in  appearance.  The  removal  of  this  clears  up  the  diag- 
nosis. Syphiloma  of  the  trachea,  as  in  the  following  case,  may  simulate 
tumor  very  closely.  A  man,  aged  40,  complaining  of  severe  dyspnea  and 
slight  dysphagia,  was  found  to  have  a  sessile  tumor  projecting  from  the 
right  posterior  wall  of  the  trachea.  There  was  a  strong  suspicion  of 
malignancy,  but  as  it  is  the  author's  rule  to  apply  the  therapeutic  test 
to  all  (|uestionable  cases  of  malignancy  no  specimen  was  taken  in  this 
case.  Foiu-  weeks  of  antiluetic  treatment  cleared  up  the  tumor  com- 
pletel}'.  In  another  similar  case  a  specimen  was  removed  because  of  the 
exceedingly  strong  suspicion  of  malignancy.  Dr.  W'illetts  reported  the 
specimen  as  certainly  not  malignant  and  with  a  strong  suspicion  of  lues. 
Treatment  \eritied  the  biopsy.  Most  important  of  all  is  not  to  mistake 
an  aneurysm  which  is  invading  the  trachea  for  a  tumor.  This  is  perhaps 
the  one  mistake  which  absolutely  must  not  be  made.  An  aneurysm  of 
sufificient  size  and  duration  to  invade  the  tracheal  wall  can  be  diagnosti- 
cated by  the  internist,  the  fluoroscopist  and  the  radiographer.  The  en- 
doscopic appearances  of  aneurysm  are  rather  of  compression  than  of  a 
neoplasm  involving  the  tracheal  wall.  The  lumen  is  apt  to  be  more  or 
less  scabbard-like  in  shape.  There  may  not  be  an  abnormal  amount  of 
pulsation.  The  endoscopic  appearances  of  aneurysm  are  elsewhere  men- 
tioned. 

Brouchoscopic  removal  of  benign  groiulhs  of  the  trachea  presents 
but  little  difficulty  if  proper  forceps  are  used.  The  author  has  had  great 
satisfaction  in  all  sorts  of  removal  of  tissue  from  the  larynx,  trachea, 
bronchi  and  esophagus  with  the  forceps  shown  in  Fig.  3.").  They  will  bite 
into  the  lateral  wall  if  the  movable  jaw  be  forced  toward  the  wall.  The 
jaw  should  be  set  so  as  to  rise,  in  the  normal  position  of  the  handle.     In 


BENIGN  C.ROWTIIS  TKIMAKV   IN   TKACHHOBRONCHIAL  TREli.  435 

case  of  large  tumors  producing  great  dyspnea  quick  action  may  be  nec- 
essary because  the  dyspnea  is  apt  to  be  increased  by  the  spasm  incidental 
to  the  presence  of  the  bronchoscope  in  the  trachea.  Under  no  circum- 
stances whatever  should  a  general  anesthetic  be  used  for  such  an  oper- 
ation. The  larynx  may  be  locally  anesthetized  and  the  bronchoscope  in- 
serted with  an  assistant  holding  the  forceps  in  readiness  for  immediate 
removal  as  soon  as  discovered.  Of  course,  the  presence  of  tumor  may 
not  be  suspected,  but  in  every  case  of  dyspnea  the  endoscopist  should  be 
prepared  for  every  emergency.  The  risks  of  removal  are  ver\-  slight 
so  far  as  hemorrhage  is  concerned  if  the  growth  is  small,  even  if  it  is 
angiomatous,  provided  it  is  not  fungations  on  an  aneurysmal  erosion. 
The  blood  from  a  slow  oozing  will  be  coughed  out.  before  the  clots  break 
down. 

Edi'iihitoiis  f'dlypi  ill  the  tn'clu'o-hroncliial  tree.  Edematous  polypi 
and  otb.er  more  or  less  tumor-like  inflammatory  sequelae  are  not  infre- 
(luently  seen  in  connection  with  the  mixed  infections  following  ulcera- 
tir)n  from  maliirnant  or  other  diseases. 


CHAPTER     XXIV. 

Benign  Neoplasms  of  the  Esophagus. 

The  author  is  unable  to  add  anything  from  personal  experience  to 
the  single  case  reported  (Rib.  ?li9,  p.  113).  In  the  author's  experience, 
therefore,  benign  tumors  of  the  esophagus  are  among  the  most  rare  af- 
fections. He  haa  seen  a  number  of  cases  of  edematous  polvpi  associated 
with  other  lesions,  benign  and  malignant,  and  one  without  any  associated 
lesions  that  could  be  determined  at  the  time  of  the  esophagoscopy.  The 
specimens  were  reported  upon  by  Dr.  Ernest  W.  W'illets  as  edematous 
tissue  with  more  or  less  fibrous  connective  tissue,  and  with  a  layer  of 
squamous  epithelium.  These,  of  course,  were  not  true  neoplasms,  but, 
like  similar  tumors  in  the  nose,  were  the  result  of  i)rolonged  inflammation. 
The  author  has  also  seen  a  number  of  cases  of  granulomata,  and  in  one 
instance,  a  mass  of  scar  tissue  that  resembled  a  cheloid.  A  few  cases 
of  varicosities  resembling  angiomata  were  seen  and  will  be  mentioned 
under  Diseases  of  the  Esophagus.  Guisez  (Bib.  178)  mentioned  reports 
of  retention  cysts  by  Sappey,  Klebs  and  Zahn ;  epithelial  cysts  by  Wyss : 
congenital  cysts  associated  with  tracheo-esophageal  fistulae  by  Eppinger 
and  Petrow ;  dermoid  cysts  by  \\'attman ;  warts  similar  to  dermal  ver- 
ruccae  by  Klebs :  papillomata  by  Reher ;  fibromata  and  lipomata  by  La- 
boulbene ;  myomata  by  Zenker,  I'ichler,  Eberth  and  Blagoviechienski ; 
adenomata  bv  \\'eigert  and  Minski.  The  references  are  not  given;  but 
presumably  the  cases  were  mostly,  if  not  altogether,  rejiortcd  in  the  pre- 
esophagoscopic  days  from  autoptical  findings. 


CHAPTER     XXV. 

Endoscopy  in  Malignant  Disease  of  the  Larynx. 

l''ollo\viiii^  llic  initiative  ot  Sir  Felix  Scmon  and  Mr.  Ilutlin.  tho  an- 
thiir's  thyrotomies  for  intrinsic  laryngeal  malignancy  of  small  extent 
have  yielded  such  a  large  percentage  of  cures,  that  he  feels  that  it  would 
be  a  step  backward  to  attempt  endoscopic  extirpation.  Therefore,  in 
the  author's  opinion,  the  usefulness  of  direct  laryngoscopy  is  confined  to 
diagnosis  of  the  disease,  and,  e<|ually  important,  to  assist  in  deciding  tlie 
(|uestion  of  ojierability.  -As  urged  by  Semon  no  specimen  should  be 
taken  in  a  case  clinically  malignant,  unless  the  patient  has  already  con- 
sented to  operation  in  the  e\ent  of  biopsic  confirmation.  This  applies 
with  especial  force  to  intrinsic  disease.  The  technic  of  taking  a  speci- 
men by  direct  laryngoscopy  is  given  in  Chapter  \TI.  T-'articular  attention 
is  called  to  the  author's  metliod  of  operating  at  the  side  of  the  tongue  in 
stead  of  over  the  dorsum.  The  autlior  has  had  uniformly  good  results 
from  bi()|)sy  in  malignancy  since  taking  the  specimens  bv  the  direct 
nK-tbiid.  which  is  in  marked  contrast  to  prior  results  from  the  indirect 
method.  C'omplications  after  taking  a  specimen  are  rare  if  the  case  is 
m;dignant.  They  are  the  same  as  might  follow  anv  endolaryngeal  o|)era- 
tion  ((|.  V.  ).  In  i-ase  of  a  gunnua  on  the  eve  of  breaking  down,  the  ])rocess 
m;iy  be  hasteneil  and  prompt  specific  treatment  will  be  necessar\-. 

The  decision  as  to  the  operability  of  atiy  laryngeal  malignancv  de- 
pends u])on  whether  the  ])arty  wall  is  inxuKed  or  not.  !n\dl\ement,  no 
matter  how  slight,  means  the  patient's  chances  arc  slender,  no  mallei- 
how  radical  the  operation,  liecause  of  the  free  lymi)lialic  leakage.  The 
degree  of  involvement  can  be  determined  by  clirect  laryngoscojiic  and 
esophagoscopic  examination  of  the  party  wall,  on  its  anterior  and  pos- 
terior surfaces.  The  esophageal  s]ieculnm  is  useful  here.  In  a  number 
of  instances  the  author  has  found  involvement  of  the  p;irty  wall  below 
the  arNtenoids  posteriorly  in  cases  free  from  ;n\tenoid  lixation  and 
seemingly  intrinsic.  In  (jther  cases,  e.xtrinsic  by  (origin  or  extension,  he 
has  advised  against  laryngectomy  because  of  glandular  nodes  observable 


4;i8 


ENDOSCOPY  IN   MALIGNANT  DISEASE  OF  THE  LARYNX. 


esophagoscopically  in  the  esophagus,  though  covered  with  apparently 
normal  mucosa.  In  one  such  illustrative  case  a  series  of  nodes  were 
seen  at  different  locations  from  the  left  pyriform  sinus  to  the  level  of 
the  upper  thoracic  aperture,  indicating  unremovable  involvement.  The 
patient  dying  shiirtly  afterward,  enabled  autoptical  confirmation  bv  Dr. 
Andrews   (Fig.  oS!)  i. 

Malignant  disease  of  the  epifflottis  may  be.  in  very  rare  instances, 
an  exception  to  contraindication  of  endoscopic  e.xtirpation  of  malignancy. 


Fig.  389. — Illustratin.tr  the  possiliilities  of  csophagoscopic  aid  in  decision  as  to 
operability  of  lanngeal  malignancy.  The  author  saw  esophagoscopically  the  lymph 
nodes,  A,  B,  C,  D,  and  others  during  life  and  advised  against  laryngectomy. 


In  those  rare  cases  of  malignancy  strictly  limited  to  the  tip  of  the  epiglot- 
tis and  of  small  extent,  endoscopic  removal  is  justifiable  provided  the 
amputation  of  the  epiglottis  will  give  a  sutlicientlv  wide  removal.  The 
author  has  had  two  cases  of  this  kind,  now  well  at  the  age  of  four  years 
and  two  years  respectively.  The  method  used  was  amputation  as  nearly 
total  as  possible,  of  the  epiglottis  with  the  heavy  snare.  Fig.  41.  The 
disease  was  of   very  small   extent  and  histologically  was   found  by   Dr. 


ENDOSCOl'V    IX    iMALIC.NANT  DISKASli  OF  THE  LARYNX.  439 

W'illetts  to  be  epitlieliomatous.  Healing  was  prompt  and  uncomplicated. 
Dela\an  (Bib.  11"  )  reports  a  cure  of  epiglottidean  maHgnancy  by  indi- 
rect removal. 

Radium  for  mal'ujnmit  disease  of  the  larynx.  As  yet  radium  has 
not  given  results  that  would  warrant  its  use  in  any  operable  case  in  the 
larynx  or  elsewhere.  In  inoperable  cases  excellent  palliative  results  war- 
rant its  use.  The  dosage  and  screening  required  are  about  the  same  as 
will  he  given  later  for  esophageal  malignancy.  The  container  with  heavy 
dosage  may  be  held  in  place  under  ocular  observation  as  was  done  by 
Dr.  Ellen  J.  Patterson  for  thirty  minutes  at  each  sitting  using  cocaine 
anesthesia.  Or  a  tracheotomy  may  be  done,  the  capsule  placed  above 
the  tracheotomic  cannula  t(j  which  it  is  tied  with  braided  silk  as  is  done 
with  the  author's  laryngostomy  apparatus  (q.  v.).  The  following  is  a 
report  of  Dr.  Ellen  J.  Patterson's  case: 

indirect  laryngoscopy  showed  the  condition  sketched  at  .A,  Fig.  :i:io. 
The  left  side  was  apparently  uninvolved,  but  on  the  right  the  entire 
aryepiglottic  fold  including  the  arytenoid  eminence  was  infiltrated,  thick- 
ened and  covered  with  nodules  of  a  dark  reddish  color.  There  was  only 
slight  movement  of  the  right  arytenoid.  The  growth  seemed  to  involve 
the  external  portion  of  the  \entricular  band  and  there  was  a  slight  in- 
filtration at  the  Iiase  of  the  epiglottis  on  the  right  side.  A  large  mass  of 
glands  was  palpable  in  the  neck  low  down  along  the  sternomastoid  muscle. 
A  large  specimen  was  removed  and  submitted  to  Dr.  Ernest  W.  W'illetts, 
Professor  ( )scar  Klotz,  Dr.  W.  Proescher  of  Pittsburgh,  and  Dr.  K\ans 
of  Chic:igo,  all  of  whom  re|iorted  the  growth  to  be  sarcoma.  The  jia- 
tient  was  not  seen  .'igain  until  one  month  later.  Upon  indirect  examina- 
tion the  growth  had  almost  doubled  in  size  overhanging  the  glottis  as 
shown  at  I!,  Fig.  oini.  There  was  now  not  the  slightest  motion  to  the 
right  arytenoid  and  the  left  seemed  to  be  slightly  impaired.  There  was 
a  very  slight  put'tiness  about  the  base  of  the  left  arytenoid  eminence.  The 
disease  was  clearly  inoperable  because  of  the  very  large  mass  of  infil- 
trated glands  in  the  neck,  the  nodes  seen  esophagoscopically,  and  the 
crossing  of  the  process  i)ast  the  posterior  commissure.  At  the  request 
of  the  patient  radium  treatment  was  instituted  by  Dr.  Patterson  under 
the  advice  of  Dr.  W.  Proescher  as  to  dosage  and  duration.  Radium 
bromide  equivalent  to  l'>  mgm.  of  radium  element  was  applied  daily  for 
thirt\'  minutes,  the  well  screened  capsule  being  placed  in  contact  with  the 
longest  diameter  of  the  growth.  In  addition,  the  patient  was  given  a 
capsule  containing  .V)  mgm.  of  radium  element  which  was  bandaged  over 
the  infiltrated  mass  of  glands  in  the  neck  for  ten  hours  daily.  After  one 
month's  treatment  with  the  radium  the  condition,  which  had  been  as 
shown  at  H.  h'ig.  oiin,  liad  entirely  disappeared,  leaving  both  aryepiglottic 


4-40 


HNDOSCOP-i-  IN    MALIGNANT  DISKASK  OF   THE  LARYNX. 


folds  and  arytenoids  almost  symmetrical  as  shown  at  C.  Tiiere  was 
quite  an  imjiroved  motility  of  the  right  arytenoid,  though  it  was  not  able 
to  make  more  than  half  a  normal  excursion.  The  patient  was  not  seen 
again  until  two  months  later  when  it  was  found  that  there  was  an  ede- 
matous-looking  slight  enlargement  of  the  right  aryepiglottic  fold,  though 
it  was  not  nodular  and  not  of  the  dark  color  of  the  primary  condition. 
Down  on  the  posterior  surface  of  the  right  aryepiglottic  fold  there  could 
be  seen  the  upper  edge  of  an  ulcer  which  extended  downward  into  the 
right  pyriform  sinus,  involving  its  anterior  wall,  as  shown  at  D.  When 
the  lar\nx  was  drawn  forward  with  the  direct  laryngoscope,  the  ulcer 
was  seen  to  extend  nearly  2  cm.  down  into  the  hypopharynx.  Dr.  Pat- 
terson removed  a  specimen  from  the  edge  of  this  ulcer.  Dr.  Ernest  W. 
AVilletts   reported   it   to  be   an   undoubted   epithelioma   with   typical   epi- 


FlG.  390. —  I  lliiMraliiiy  a  c.ix.-  ui  l.iiviiytal  sarniiiia  in  a  man  ol  37  \ears.  The 
growth  (B)  disappeared  under  radium  treatment  as  shown  at  C.  Epithelioma  ap- 
peared later  as  shown  at  D.  Heavier  radium  dosage  caused  disappearance  of  the 
epithelioma.  The  growth,  prior  to  treatment,  had  increased  from  the  size  shown 
in  A  to  the  size  shown  in  B.  Death  occurred  about  a  year  hiter  of  recurrence  and 
metastases  (Case  of  Dr.  Ellen  J.  Patterson.) 


theliomatous  cell  pictures.  Drs.  I'roescher  and  Klotz  concurred  unquali- 
fiedly. Under  the  advice  of  Dr.  Proescher  radium  bromide  equivalent 
to  201)  mgm.  of  radium  element  was  applied  for  a  half  hour  on  alternate 
days  for  five  applications.  This  caused  the  disappearance  of  the  growth. 
One  year  later  the  patient  died  of  recurrence  and  metastases. 

Remarks.  Lues  was  excluded  by  a  very  thorough  therapeutic  test 
by  Dr.  Lawrence  Litchfield  and  Dr.  L.  C.  Ilixler.  The  eminent  pathol- 
ogists mentioned  all  agreed  that  there  was  absolutely  no  histologic  evi- 
dence of  cancer  in  the  first  specimen  taken,  wliich  was  a  very  large  one. 
and  hence  fairly  representative  of  the  neoplastic  process  then  present. 
It  seems  justifiable  to  suppose  that  the  radium  caused  the  disappearance 
of  the  primarv  condition.  The  change  from  a  connective  tissue  type  of 
neojilasm  to  an  epithelial  ty])e  seems  to  the  author  very  rare,  as  he  had 
ne\er  before   seen   such   a  case.      Mr.   Walter  G.   Howarth,   who,   when 


ENDOSCOPY  IN    MALIGNANT  DISKASK  Ol"   Till-:  LARYNX.  44] 

honoring  the  author's  clinic  with  a  visit,  saw  the  patient  at  the  stage 
shown  at  D,  mentioned  a  case  of  his  own  in  which  there  was  a  change 
from  an  epithelial  tissue  type  to  a  connective  tissue  type.  A  papilloma 
was  removed  from  the  uvula  of  a  boy.  This  was  followed  six  months 
later  by  a  growth  in  the  \elum  bulging  both  anteriorly  and  posteriorly. 
Mr.  Howarth  removed  the  entire  velum  with  the  tonsil,  followed  by  per- 
fect healing.  This  growth  was  found  to  be  a  fibroma.  Four  months 
later  a  pedunculated  mass  developed  in  the  scar  and  was  removed  by  ex- 
ternal operation  along  with  involved  glands.  This  growth  was  found  to 
be  a  spindle-celled  sarcoma.  This  operation  was  followed  by  hopeless 
recurrence  from  which  the  last  specimen  examined  showed  a  small  round- 
celled  sarcoma.  All  of  the  specimens  were  examined  by  Mr.  Shatluck 
and  all  of  the  operations  were  done  by  Mr.  Howarth.  Such  cases  are 
exceptions  to  the  law  that  tissue  never  changes  type.  The  efficiency  of 
radium  in  prolonging  life  in  Dr.  Patterson's  case  is  undoubted  in  view 
of  the  rapid  growth  in  one  month's  time  prior  to  treatment  as  shown  by 
comparing  A  and  1!,  l-'ig.  ;'>!»0.  That  an  ultimate  cure  did  not  result  is 
disappointing,  but  the  palliative  results  were  well  worth  while. 

Diathermy.  Mr.  Douglas  Harner  reports  such  excellent  results  from 
dialhennv  in  the  treatment  of  inoperable  laryngeal  and  faucial  malig- 
nancy that  its  use  alone  or  cojointly  with  radium  promises  excellent 
palliative,  possibl\-  cmatixe  results.  (See  Journal  of  Larynyoloijy,  Nliiii- 
oloyy  and  Otoloqy,  October,  IIU 4.) 


CHAPTER     XXVI. 

Bronchoscopy  in  Malignant  Growths  of  the  Trachea. 

The  author  has  seen  but  one  case  of  maUgnant  tumor  originating  in 
the  interior  of  the  thoracic  trachea,  at  a  stage  when  such  origin  could  be 
verified.  But  such  cases  occurring  in  the  subglottic  region  of  the  larynx 
have  been  observed  by  all  laryngologists,  including  the  author,  and  post 
mortem  findings  would  indicate  that  endobronchial  or  endotracheal  origin 
does  occur.  A  case  of  cancer,  probably  arising  from  an  endotracheal 
mucous  gland  in  the  subglottic  trachea,  is  reported  by  Sir  Robert  Woods. 
The  bronchoscope  offers  a  means  for  the  early  diagnosis  of  malignant 
tumors  of  the  thorax.  As  these  tumors  occur  most  fre(|uently  at  the 
hilus,  it  is  seldom  that  even  an  early  diagnosis  renders  surgical  extirpa- 
tion ])ossible,  and  yet  with  the  rapidK  advancing  development  of  thoracic 
surgery  it  behooves  us.  as  endoscopists,  to  develop  the  early  diagnosis  of 
malignancy  to  the  utmost  in  order  to  be  of  assistance  to  the  general  sur- 
geon, .^s  is  well  known,  neither  the  X-ray  nor  [ihysical  signs  give  any 
evidence  of  inediastinal  malignancy  at  a  very  early  stage.  Posticus 
paralysis,  it  is  true,  is  cpiite  an  early  evidence,  but  in  most  cases  it  is 
simply  an  indication  for  further  investigation  in  order  to  determine 
whether  or  not  the  paralysis  is  due  to  intrathoracic  conditions.  Tlie 
most  common  form  of  malignancy  in  the  trachea  is  a  secondary  process 
from  a  peritracheal  growth.  As  enumerated  under  the  head  of  malig- 
nant disease  of  the  esophagus,  the  author  has  seen  quite  a  number  of 
cases  where  the  trachea,  or,  more  often,  the  left  bronchus  was  invaded 
by  a  tumor  which  also  invaded  the  esophagus.  It  is  not  often  possible 
to  determine  the  point  of  origin  of  the  growth.  It  may  Ije  in  the  trachea, 
in  the  esophagus  or,  more  probably,  in  the  mediastinum.  The  endo- 
tracheal appearances  are  quite  similar  to  malignant  disease  elsewhere. 
In  the  later  stages,  which  the  process  has  practically  always  reached  by 
the  time  it  comes  to  the  endoscopist,  endotracheal  and  endobronchial 
malignancy  are  characterized  by  a  bleeding  mass  of  fungatiiig  tissue 
bathed  in  ])us  and  secretion,  usually  foul.  The  diagnosis  of  a  malignant 
process  wliicii  has  already  involved  the  lumen  of  the  trachea  is  to  be  made, 
not  so  much  by  the  endoscopic  appearances  as  bv  the  removal  of  a  speci- 
men of  tissue.  Xo  danger  whatever  attaches  to  this  if  carefullv  done  and 
if  aneurysm  be  excluded.  As  elsewhere  stated,  an  aneurysm  large  enough 
to  invade  the  tracheal  lumen  can  easily  be  diagnosticated  by  radiography, 
fluoroscopy  and  by  the  internist.  Sarcoma  and  carcinoma  of  the  thyroid 
gland  when  perforating  into  the  trachea,  as  pointed  out  by  Sir  Felix 
Semon  (  Bib.  471 )  usually  become  pedunculated. 


BROXCIIOSCOPY    IX    MAI.ICiNANT    GROWTHS   OF    THE    TRACHEA.         443 

I'eritracheal  or  periljronchial  malignancy  mav  cause  a  compressive 
stenosis  co\ored  with  normal  mucosa.  Endoscopically  the  wall  is  seen 
to  bulge  in  from  one  side  at  any  part  of  the  lumen  causing  a  crescentic 
picture,  or  compression  of  oi)iiosite  walls  may  cause  a  "'scabbard"  or 
pear-shaped  lumen.  L'sually  the  compression  will  be  found  hard  and 
firm  and  the  involved  bronchus  less  easily  moved  laterally  than  normal. 
Deviation  of  the  trachea  may  be  marked  in  peritracheal  malignancy  and  is 
to  he  distinguished  from  anomalous  deviations  by  the  compressive  hard- 
ness and  fi.xation  of  the  former.  Compression  by  normal  or  malignant 
thyroids,  especially  retrotracheal  malignant  goitre  renders  bronchoscopic 
exploration  advisable  as  a  preliminarv  to  operation  as  mentioned  imder 
"Anesthesia."  The  reader  is  referred  to  the  beautiful  and  instructive 
".\tlas  der  Rronchoskopie''  by  Dr.  AT.  Mann  (Bib.  .Tlil)  for  pathological 
studies  of  cases  of  mediastinal  malignant  disease  with  endotracheobron- 
chial  manifestations  discovered  bronchoscopically :  also  to  the  excellent 
article  of  Mosher  (Rib.  4o:!),  Theisen  (Bib.  .")4Sj  and  of  Ingersol  (Bib. 
319). 

Treatment.  L'p  to  the  jircsent  time  but  one  case  of  sticcessful  ex- 
tirpation of  malignancy  has  come  to  the  writer's  knowledge.  This  was  a 
case  of  Kahler,  in  which  a  tumor  of  the  right  bronchus  was  removed 
bronchoscopically,  its  insertion  being  afterward  cauterized  with  the 
galvano-cautery.  The  tumor  was  found  to  be  a  papillary  cylinder-celled 
carcinoma.  At  the  time  of  the  report  the  patient  had  remained  free 
from  recurrence  at  the  end  of  two  and  one-half  years.  Ephraim  reports 
the  removal  of  heinorrhagic  and  obstructive  fungations  of  malignancy 
with  tile  subsequent  application  of  the  galvano-cautery  with  great  relief 
of  pain  ;uid  the  arrest  of  hemorrhage  and  the  lessening  of  dyspnea.  Un- 
til a  tlH-ra|ieutic  cure  shall  be  disco\ere<l  most  of  the  cases  will  be  sub- 
jects for  a  ])alliative  tracheotomy  and  radium  therapy.  The  methods, 
screening  and  dosage  are  proljably  about  the  same  as  those  given  for 
eso])hageal  malignancy.  In  doing  a  tracheotomy  it  is  necessary  not  only 
to  oi)en  the  trachea  to  put  in  a  cannula,  but  to  make  sure  that  that  can- 
nula gets  down  below  the  diseased  ])rocess  and  ])ipes  the  air  down  to  one 
or  both  bronchi  wiiich  arc  still  functionating.  In  ijuitc  a  number  of  the 
author's  cases  there  has  been  a  mere  fistulous  tract  kept  open  by  the 
long  tracheal  cannula  long  after  the  tracheal  wall  has  been  obliterated 
by  the  cancerous  ])rocess  throughout  a  greater  or  less  jiortion  of  its  ex- 
tent. The  patient  is  able  to  get  up  secretions  better  through  the  long 
tracheal  cannula  than  he  can  through  the  diseased  trachea  even  if  he 
could  get  air  enough  <lo\\n  without  the  cannula,  whicli  is  seldom  the  case, 
so  that  tracheotomy  with  the  long  tube  probably  prolongs  the  patient's 
life  by  lessening  the  absorption,  as  well  as  by  preventing  asphyxia. 


CHAPTER     XXVII. 

Malignant  Disease  of  the  Esophagus. 

Canctroiis  lesions  of  the  esophagus  are  usually  single.  This  is  rare- 
ly discoverable  esophagoscopically,  because  it  is  rarely  justifiable  to  push 
an  esophagoscope  beyond  the  site  of  the  first  lesion.  Nevertheless,  as  a 
post  mortem  fact,  it  has  been  demonstrated  by  Seelig  (Bib.  40!))  that 
implantation  metastases  nia\  exist  in  the  esophagus  below  the  primary 
lesion  (Fig.  391).  Malignant  disease  of  the  esophagus  is  rather  more 
frequent  at  the  upper  extremity,  next  in  frequency  is  the  lower  extremity 
near  the  cardia,  the  middle  portion  being  least  often  involved.  In  all 
cases  of  suspected  cancer,  it  is  necessary  to  exclude  aneurysm  by  radiog- 
raphy before  making  an  examination.  Then  in  proceeding  with  the 
esophagoscopy  it  is  necessary  to  exercise  great  care  to  pass  the  tube  by 
sight  and  not  with  a  mandrin,  because  the  growth  may  be  higher  situated 
than  is  suspected.  (Jf  course  this  same  rule  applies  to  all  esophagoscopy, 
Init  there  has  been  quite  a  number  of  cases  re])orted  where  the  esoph- 
agoscope had  perforated  the  very  much  weakened  wall  of  a  malignancy 
situated  close  to  the  cricopharyngeal  narrowing.  Therefore,  it  is  neces- 
sary to  be  doubly  careful,  especially  as  the  infiltration  may  make  the 
passage  of  the  esophagoscope  more  difficult  than  usual  in  this  narrow 
portion  of  the  eso])hagus.  Unfortunately,  malignant  disease  of  the  esoph- 
agus is  but  rarely  seen  early.  There  are  two  reasons  for  this.  First, 
the  early  stages  of  the  disease  produce  no  symptoms.  Second,  when 
symptoms  begin  to  appear  they  are  so  slight  that  usually  neither  patient 
nor  attending  physician  suspects  serious  disease,  calling  for  immediate 
esophagoscopy.  With  a  wider  recognition  of  the  usefulness  of  the  esoph- 
agoscope for  early  diagnosis,  there  will  be  a  change  in  this  respect.  It 
should  be  an  absolute  rule  that  no  transthoracic  operation  for  malig- 
nant disease  of  the  esophagus  should  be  attempted  until  after  a  specimen 
has  been  removed  and  the  diagnosis  confirmed.  For  the  removal  of  this 
specimen,  of  course,  the   esophagoscopic  method  is  the  onlv  one.     The 


MAl.IC.NANT  niSKASIv   OK  TIIK    KSOPII AGUS.  445 

specimen  should  be  ample,  and  should,  if  possible,  include  a  little  of  the 
adjacent  normal,  though  greater  care  is  needed  here  than  elsewhere  as 
to  the  amount  of  normal  that  may  be  taken.  A  little  of  the  mucosa  is 
suflicient.  The  only  contraindication  to  the  taking  of  a  specimen  is  such 
a  profoundly  anemic  condition  that  oozing  which  mav  follow  may  turn 
the  balance  against  llic  paliciu.  This  anemic  condition  is  usually  only 
found  in  diose  cases  that  have  been  permitted  to  become  moribund  from 
hunger  and  thirst  from  too  long  delayed  gastrostomy.  Tn  such  cases  the 
gastrostomy  sho'.'.ld  be  done  at  once  and  the  [latient  fed  until  the  specimen 
may  be  taken  with  safety.  L'nfortunately.  such  patients,  especially  if 
there  have  been  a  few  days  of  water  hunger,  make  exceedingly  bad  sur- 
gical  subjects,   so   that   the   minor  ojieration   of   gastrostomy   assumes   a 


Fk;.  391. — Implantation  nictaslasi.-s  in  the  csopluif^us.  DiaRrammatic  repre- 
sentation of  a  coiled  up  longitudinal  section.  The  primary  lesion  at  upper  end  of 
esophagus  is  seen  at  2;  at  the  lower  end  :ii  1.  Tlic  lesions  at  4  and  5  arc  metastatic, 
(Sec  article  hv  M.  C.  Seelig,  Bih.  469.) 


high  mortality.  Cases  of  suspected  cancer,  like  c\cry  other  esophageal 
condition,  should  be  examined  locally  with  an  cso])hagosco])e  before  any 
attempt  is  made  to  |)ass  any  instrument  blin<lly.  The  author  cannot 
agree  witli  those  who,  for  an\-  ptirposc  whatsoe\er  prefer  to  pass  a 
bougie  lirst.  There  lia\e  been  too  many  acciilcnts  from  this  ]irocedure, 
and  the  author  can  see  no  advantage  whatever  in  it,  for  there  is  nothing 
to  l)e  learned  by  sounding  that  cannot  be  learned  esojjhagoscopicallw  and 
so  far  as  the  patieiU  is  ccinccrned,  it  is  no  nv>[\-  .innoyancc  to  have  an 
esophagoscopc  p.'isscd  than  to  have  a  sound  passed.  As  for  the  deter- 
mining by  such  a  method  the  length  of  the  tube  to  be  used,  which  is  the 
last  remaining  excuse  given,  it  is  (|uite  needless.  The  .luthor's  custom  is 
to  examine  the  upper  region  of  the  esopiiagus  lirst  with  the  esophageal 


44(5  MALIGNANT  DISEASE  OF  THE  ESOPHAGUS. 

speculum  and  then  to  pass  the  53  cm.  esophagoscope.  which  is  the  only 
one  needed  for  adults.  Sarcoma  is  much  less  frequent  than  carcinoma 
but  does  occasionally  occur.  It  is  exceedingly  seldom  that  there  is  any 
dilatation  above  a  cancerous  stenosis,  possibly  because  the  stenosis  is 
seldom  sufficiently  obstructive  until  late  in  the  disease.  Occasionally, 
however,  quite  a  considerable  dilatation  has  been  observed  by  the  author 
which  leads  to  the  suspicion  that  there  was  some  spasmodic  condition 
prior  to  the  development  of  cancer,  and  possibly  the  cancerous  process 
was  implanted  upon  the  chronic  inflammation. 

Esophagoscopic  appearances  and  diagnosis  of  malignant  disease  of 
the  esophagus.  The  esophagoscopic  appearances  of  cancer  vary  greatly, 
according  to  the  stage  in  which  the  disease  is  seen,  and  also  according  to 
whether  the  esophagus  or  neighboring  viscera  are  jirimarily  invaded. 
The  following  forms  of  lesion  are  those  usually  seen : 

1.  Submucosal  infiltration  covered  by  perfectly  normal  membrane, 
usually  associated  with  more  or  less  bulging  of  the  esophageal  wall,  and 
usually  associated  with  hardness  and  infiltration. 

2.  Leucoplakia. 

3.  Ulceration  projecting  l)ut  little  above  the  surface  at  the  edges. 

4.  Rounded  nodular  masses  grouped  in  mulberry-like  form,  cither 
dark  or  light  red  in  color. 

.5.     Polypoid  masses. 

6.     Cauliflower  fungations. 

In  considering  the  esophagoscopic  appearances  of  cancer,  it  is  neces- 
sary to  remember  that  after  ulceration  has  set  in  the  cancerous  process 
may  have  engrafted  upon  it,  and  upon  its  neighborhood,  the  results  of 
inflammation  due  to  the  mixed  infections.  Cancer  invading  the  wall 
from  without  may  for  a  long  time  be  covered  with  perfectly  normal 
mucous  membrane.    The  significant  signs  at  this  early  stage  are  : 

1.  Absence  of  one  or  more  of  the  normal  radial  creases  between 
the  folds. 

2.  Asymmetry  of  the  ins]iiratory  enlargement  of  lumen. 

3.  Sensation  of  hardness  of  the  wall  on  pal])ation  with  the  tube. 

4.  The  involved  wall  will  not  readily  be  made  to  wrinkle  when 
pushed  upon  with  the  tube  mnuth. 

In  determining  deformit\-  of  the  outline  of  the  esophageal  lumen, 
it  is  necessary  to  be  careful  that  the  head  of  the  patient  is  not  rotated: 
because  rotation  may  cause  distortion  of  the  esophagus  as  demonstrated 
graphically  in  the  radiogra]>h.  Fig.  392.  In  the  later  stages,  when  the 
submucosal  growth  begins  to  break  through,  the  mucous  membrane  be- 
comes nodular,  and  then  is  usually  darker  in  color  with  apparent  great 
increase  of  vascularity.     In  the   fungating  forms  of  cancer,  the  funga- 


MALIGNANT  DISKASIC  OK  THE  KSOPHAGUS. 


447 


tions  may  lake  a  polyimid  sliai'L-,  tin-  individual  jjolypi  being  covered  witii 
epithelium  and  the  general  color  being  quite  similar  to  normal  esophageal 
mucosa  or  to  nasal  edematous  (lolypi,  or  they  may  be  (|uite  red.  This 
latter  form  is  rather  rare.  Much  more  common  are  the  fungations  which 
look  like  exuberant  granulations  in  an  unhealthy  woiuul.  We  also  oc- 
casionally see  white  grass-like  [irojections  such  as  are  seen  at  times  in  the 


Fig.  3QJ. — Radiograiih  of  a  coin  in  the  esophagus,  showing  the  diagonal  res- 
piratory esophageal  movement  with  rotated  head,  and  illustrating  the  necessity 
of  the  exact  median  non-rotated  position  nf  tlie  head  if  any  diagnostic  importance 
is  to  be  attached  to  asymmetrical  respiratory  esophageal  movement  in  escphagos- 
copy  for  suspected  periesophageal  or  submucosal  esophageal  lesions.  Incidentally 
this  illustrates,  also,  one  of  the  disadvantages  of  the  lateral  position  for  esoph- 
agoscopy  for  disease.     Radiograph  by  Dr.  George  J.  Boyd. 


larynx.  The  ulcerated  fcirms  of  esophageal  malignancy  seldom  resemble 
ulceration  seen  in  the  nuicosa  hit;her  up.  I'art  of  this  seeming  dissimi- 
larity is  due  to  the  |iosilion  in  which  the  ulcer  lies  with  reference  to  the 
jioint  of  view.  I'lceratinn  in  the  csojihagus  is  seen  more  or  less  on  edge 
throtigh  the  esoiihagoscopc,  and  because  of  the  basal  infiltration,  it  is 
seldom   feasible  to  turn  the  ulcer  sidewise,  as  could  be  dotie  by  lateral 


448  MALIGNANT  DISEASE  OF  THE    ESOPHAGUS. 

pressure  on  the  esophageal  wall  above  the  ulcer  if  it  were  not  for  the 
infiltration  beneath,  [f  a  very  large  esophagoscope  is  used,  there  is  more 
or  less  turning  of  the  ulcer  and  then  the  crater  can  be  seen,  and  also  the 
distal  edges.  The  edges,  in  some  instances,  are  under  cut.  though  usually 
not.  In  many  instances  there  are  smaller  budding  granulations  along 
the  edge  of  the  ulceration.  In  some  instances,  the  ulcerations  are  cov- 
ered with  whitish  projections,  looking  somewhat  like  papillomata,  but 
the  individual  projections  are  more  pointed.  The  center  may  be  some- 
what lower  than  the  periphery,  and  in  many  instances  is  covered  with  a 
layer  of  exudate,  whitish  or  yellowish  in  color,  the  exact  color  depend- 
ing, of  course,  on  the  degree  of  illumination.  There  is  almost  invariably 
more  or  less  oozing  of  blood,  even  before  an\-  instrument  or  gauze  sponge 
has  come  in  contact  with  the  ulcerated  surface.  In  some  instances,  the 
border  may  be  very  irregular  with  a  mouse-gnawed  ajipearance  to  the 
edges.  In  one  of  the  author's  cases  the  ulcerated  area  seemed  flat,  almost 
depressed,  while  on  top  of  it  was  lying  a  mass  of  slough  and  exudate, 
apparently  about  ready  to  detach.  All  of  the  foregoing  types  may  occur 
in  the  same  case,  either  at  different  stages  or  all  may  co-exist  in  one 
lesion.  It  is  quite  common  to  see  at  least  two  forms  combined  in  the 
same  lesion.  Two  things  are  characteristic  of  all  later  forms  of  lesions. 
All  are  bleeding  when  first  seen,  or  bleed  very  readily  when  wiped  with 
the  sponges.  They  all  convey  the  idea  of  rigiditv  or  fixation  of  the  in- 
volved area,  which  is  in  marked  contrast  to  the  normally  thin,  easily 
movable,  supple  esophageal  wall.  There  is  every  reason  to  believe  that 
the  very  early  stage  of  cancer  occurs  as  leucoplakia  in  at  least  a  few 
cases  of  esophageal  cancer.  There  have,  so  far,  been  only  a  few  cases 
observed,  but  opportunity  for  very  early  esophagoscopies  in  cancer  are 
so  rare  that  there  is  no  means  of  determining  how  frequent  such  an  on- 
set may  Ije.  The  author  has  seen  three  cases  of  which  the  following  is 
one: 

•Male,  aged  .")il,  was  admitted  to  the  Presbyterian  Hospital  for  diffi- 
culty in  swallowing  of  about  two  weeks'  duration.  The  onset  had  been 
c|iiite  sudden,  at  which  time  he  had  been  unable  to  swallow  anything  but 
liquids.  On  passing  the  esophagoscope.  we  encountered,  just  above  the 
hiatal  level,  a  white  patch  about  1  cm.  in  diameter  that  looked  precisely 
as  if  the  mucosa  had  been  burned  with  silver  nitrate.  The  appearance 
was  so  much  like  that  of  the  mucous  plaque,  and  the  onset  of  the  symp- 
toms had  been  so  recent,  that  we  ordered  the  patient  at  once  put  upon 
antiluetic  treatment,  notwithstanding  a  negative  history  and  normal 
glands.  At  the  end  of  four  weeks  there  was  no  amelioration  of  the 
symptoms,  and  on  passing  the  esophagoscope  I  found  conditions  jirecisely 
as  before.     .\t  neither  of  these  two  examinations  could  I  determine  anv 


MALIGNANT  DISEASE  OF  THE    ESOPHAGUS.  449 

Stenosis  of  the  esophagus.  The  10  mm.  esophagoscope  passed  readily 
into  ihe  stomach  without  obstruction,  so  that  it  was  quite  evident  that 
the  symptoms  from  wliich  the  patient  suffered  must  have  been  due  to 
spasm,  though  we  were  somewhat  surprised  that  the  passage  of  the  esoph- 
agoscope the  first  time  had  not  reHeved  the  symptoms,  temporarily  at 
least,  as  is  usual  in  case  of  spasm.  This  patient  went  west  and  died  of 
"cancer  of  the  stomach."  A  gastrostomy  was  done  for  feeding  about 
two  months  before  his  death.     Xo  other  data  were  obtainable. 

Sarcoma  of  the  csophaijiis  probably  resembles  in  a  general  way  the 
appearances  seen  in  cancer.  The  author  has  seen  but  one  case  of  esopli- 
ageal  sarcoma.  There  was  a  round  nodular  mass  on  the  posterior 
esophageal  wall.  (|uile  dark  in  cnlor  and  covered  with  vessels  running  in 
all  directions.  At  ibc  lower  border  was  an  ulceration,  with  elevated  edges 
and  depressed  center  (  b'ig.  !l,  J'late  III).    No  fetor  was  noticeable. 

Differential  diagnosis.  The  differential  diagnosis  by  esophagoscopic 
appearances  alone,  while  not  absolutely  positive,  yet  will  be  rarely  in 
error  with  any  one  who  is  accustomed  to  seeing  malignancy  of  mucosal 
surfaces.  In  cicatricial  stenosis,  we  have  a  thin,  white,  web-like  band, 
'or  thin-edged  annular  stricture  with  a  dilatation  above  it.  In  spasmodic 
conditions,  we  have  the  vertical  fold  running  down  into  a  funnel-shaped 
l)oint  ending  in  a  concentric  lumen  of  minute  extent;  the  mucosa  is 
either  normal  or  pasty  and  macerated,  or  in  a  state  of  chronic  esophagitis. 
This  condition  is  usually  more  or  less  diffused,  and  there  is  an  absence 
of  that  rigidity  and  infiltration  that  is  seen  in  malignancy.  In  the  ul- 
cerated type  of  cancer,  it  may  be  exceedingly  difficult  to  exclude  lues 
without  a  therapeutic  test.  The  differential  diagnosis  between  compres- 
sion stenosis  and  cancer  of  the  submucous  type,  is  based  upon  the  rigidity 
and  fixedness  existing  in  the  esophageal  wall,  and  the  fact  that  this  wall 
cannot  be  wrinkled  up  in  cancer  while  it  is  freely  movable  in  c()mi)res- 
sion.  In  com])ression  a'so  we  have  oljliteration  of  the  lumen  to  a  long 
nariiiw  slit.  In  llie  leuc<]iilakia  t\pe.  mucous  patches  of  lues  can  be  ex- 
cluded only  by  the  therapeutic  test.  After  all,  we  must  rely  mainly  upon 
the  histologic  examination  of  an  esophagoscopically  removed  specimen 
wliich  should,  in  all  cases,  be  as  amjile  as  possible  and  should  include  a 
l>()rtion  of  the  adjoming  normal. 

'I'rcatmoit  of  mdliijiiant  disease  of  the  eso[>hu(/HS.  Cancer  of  the 
esophagus  has,  at  the  jiresent  day.  I'lo  |ier  cent  mortality,  but  there  is 
good  reason  to  believe  that  the  surgeon  will  show  a  certain  percentage  of 
cures  as  soon  as  ]ihysici;uis  will  i>rom]itl\-  refer  to  the  esophagoscojiist  all 
patients  showing  the  slightest  abnurmality  referable  U<  the  esophagus. 
Thus  only  can  we  ho[)e  to  discover  and  treat  the  early  cancerous  and 
precancerous    conditions    of    leucoplakia,    erosion,    maceration,    chronic 


450  MALIGNANT  DISEASE   OF  THE    ESOPHAGUS. 

esophagitis,  etc.  That  the  physician  may  do  this  without  hesitation,  it  be- 
hooves the  esophagoscopist  to  so  perfect  his  technic  and  develop  his 
skill  that  a  patient  may  be  esophagoscoped  without  distress  and  without 
anesthesia,  or  at  most  with  local  anesthesia  limited  to  the  pharynx.  The 
work  of  Henry  Janeway,  Willy  Mayer,  Charles  A.  Elsberg  and  others 
has  convinced  the  author  that  resection  of  the  thoracic  esophagus  is  a 
practicable  procedure  and  will  be  frequently  resorted  to  as  soon  as  early 
esophagoscopies  shall  make  the  necessary  early  diagnosis.  The  passage 
of  an  esophagoscope  for  diagnosis  often  gives  great  relief  of  dysphagia, 
and  this  has  lead  to  advocacy  of  the  old  method  of  bouginage.  It  is, 
however,  of  questionable  advisability  even  for  palliation. 

Gastrostomy  is  always  indicated  sooner  or  later,  and  it  should  al- 
ways be  done  before  the  patient's  nutrition  fails.  Like  tracheotomy,  we 
all  preach  its  early  performance,  but  usually  do  it  late.  The  surgeons 
who  advise  against  gastrostomy  forget  that  their  experience  is  based  on 
cases  operated  too  late.  Granting  that  the  patient  is  a  victim  of  a  fatal 
disease,  there  is  no  reason  why  he  should  die  in  the  agonies  of  thirst  and 
hunger.  Death  from  exhaustion  is  fairly  comfortable,  but  death  from 
hunger  and,  especially  thirst,  is  agonizing,  and  the  agony  is  prolonged- 
by  the  tantalizingly  small  amount  of  fluid  that  passes  the  stenosis.  If 
the  gastrostomy  be  done  early,  there  is  no  unquenchable  thirst,  no  un- 
satisfied hunger,  and  most  beneficent  of  all,  is  the  almost  invariable  im- 
provement in  the  ability  to  swallow  through  the  esophagus  that  follows 
the  esophageal  rest  after  gastrostomy. 

Intubation  of  the  esophagus.  In  the  palliative  treatment  of  inoper- 
able esophageal  cancerous  stenosis,  gastrostomy  may  be  postponed  by 
esophageal  intubation,  in  many  instances,  until  very  nearly  the  termina- 
tion of  the  case,  though  by  this  it  is  not  meant  to  advise  that  gastrostomy 
should  be  postponed  one  day  after  it  is  clear  that  nutrition  is  going  to 
suffer.  It  is,  of  course,  much  more  satisfactory  to  tiie  patient  to  swallow 
his  food  even  though  it  be  liquid,  than  to  have  it  poured  in  through  the 
abdominal  wall.  Esophageal  intubation  has  been  very  satisfactory  in 
the  atithor"s  hands.  All  forms  of  clear  liquids  will  go  through  esoph- 
ageal intubation  tubes  of  4  mm.  internal  diameter,  and  raw  or  very 
slightly  cooked  eggs  can,  with  care,  be  swallf)weil  witli  much  satisfac- 
tion by  the  patient  whose  esophagus  is  thus  intubated.  In  fact,  any  finely 
masticated  food  will  go  through,  though  occasionally  imperfectlv  mas- 
ticated particles  may  lodge  in  the  smallest  tubes.  The  author  has  had 
these  tubes  worn  for  quite  a  number  of  months  without  exciting  ulcera- 
tion, though,  of  course,  cancerous  ulceration  was  already  present  in  some 
instances.  The  tubes  should  be  removed  every  week  or  two  for  clean- 
ing.    It  is  essential  to  have  a  duplicate  tube  fi)r  immediate  replacement 


MAi.ii'.XAXT  riisTA^i'  CI'   iin    I  scirii  Ar.r-- 


451 


Fif!-  393- — CliartiTs  Symonds  esoplKiKial  iiuuli.ili 
esophageal  caiucr      (  Xmhnr's  case). 


11   uiliis   in   >iiu  in  a  ca^c  ol 


452 


MALIGNANT  DISEASE  OF  THE  ESOPHAGUS. 


else  the  esophageal  channel  will  quickly  close  so  that  a  smaller  tube  will 
be  needed.  Eventually  a  smaller  and  a  smaller  tube  is  needed  anyway, 
until  none  can  be  introduced.  The  Charters  Symonds  tube  was  intended 
for  introduction  with  a  whalebone  stylet,  without  endoscopic  aid.  In- 
troduction is  greatly  facillitated.  however,  by  drawing  forward  the 
larynx  with  the  laryngoscope.  The  thread  may  be  dispensed  with  and 
withdrawal  accomplished  when  necessary  with  the  esophagoscope  and 
forceps.  In  removal  of  the  esophageal  intubation  tube  by  the  thread 
without  the  esophagosco])e  the  funnel-shaped  tube  will  always  catch  on 
the  cricoid  cartilage  and  serious  traumatism  may  be  inflicted  if  the  oper- 
ator continues  to  pull.  Drawing  the  larynx  anteriorly  with  the  laryngo- 
scope or  esophageal  speculum,  just  as  if  we  were  exposing  the  crico- 
pharyngeal  constriction,  will   readily  release  the  tube  so  that  it  can  be 


l-iG.  394. — Esophageal  intiibntion  tube  of  Guisez. 


withdrawn.  This  is  a  very  important  procedure  to  remember  in  the 
withdrawal  of  any  instrument  from  the  esophagus.  Serious  and  even 
fatal  trauma  has  been  inflicted  more  often  in  the  withdrawal  of  such 
instruments  as  the  Graefe  basket  than  in  their  insertion.  The  Charters 
Symonds  tube  hi  situ  is  shown  in  Fig.  oiKl.  C.uisez  has  devised  soft  rub- 
ber intubation  tubes  that  seem  excellent  (Fig.  '-VJi). 

Radium  in  the  treatment  of  esophageal  maliiinancy.  The  author 
has  not  yet  seen  any  results  with  radium  that  would  justify  his  urging 
its  use  in  any  case  that  is  amenable  to  operative  treatment.  He  has  seen 
marked  eft'ects  in  inoperable  esophageal  malignancy,  but  so  far  no  abso- 
lute cures.  In  none  of  the  cases  has  sufficient  time  elapsed  to  pass  final 
judgment  upon  the  value  of  radium  therapy  in  neoplasms.  The  author 
would  prefer  to  wait  for  three  or  four  years  before  giving  complete  and 


MALIGNANT  DISKASK  OI"  THE  KSOI'II AGUS.  453 

tabulated  data  of  his  results.  In  order,  however,  that  other  workers  in 
this  field  may  have  the  use  of  such  technic  as  the  author  has  developed, 
he  deems  it  best  to  i)ublish  this  technic  in  the  hope  that  it  may  be  helpful 
to  other  workers.  The  chemistry,  physics,  and,  to  a  still  greater  extent, 
the  physiologic  and  therapeutic  activities  of  radium  are  in  such  an  em- 
brj'onic  state  of  development  at  the  time  this  book  goes  to  press,  that 
it  is  quite  impossible,  even  if  the  author  were  capable,  to  give  any  final 
conclusion.  For  all  work  with  which  endoscopj'  has  to  deal,  the  con- 
sensus of  opinion  is  that  the  penetrating  or  gamma  rays  are  the  most 
effective.  To  avoid  the  irritating  effect  and  burns  that  the  softer  beta 
rays  would  produce,  it  is  necessary  to  absorb  these  rays  with  suitable 
thickness  of  metal  screen,  usually  silver  or  lead  of  from  0..5  to  3  mm. 
in  thickness.  \\'herever  gamma  rays  emerge  from  a  metal  there  are  set 
up  secondary  radiations,  which  are  soft  like  the  very  easily  absorbed 
beta  rays.  These  secondarj'  rays  are  very  irritating  and  soon  produce 
serious  superficial  burns.  To  avoid  these  deleterious  efl:'ects,  it  is  neces- 
sary further  to  screen  the  metal  outside  with  the  equivalent  of  1  or  3 
mm.  of  rubber,  cloth  or  paper.  When  so  screened  with  lead  and  rub- 
ber, a  quantity  of  radium  equal  to  IDO  mgm.  of  element  can  be  applied  for 
hours  without  jiroducing  a  burn,  whereas,  10  mgm.  of  radium  with  no 
more  [)rotcction  than  the  walls  of  a  glass  tube,  in  contact  with  the  tis- 
sues for  ten  minutes,  will  lead  to  serious  burns.  The  shorter  the  period 
of  application  of  radium,  the  larger  the  quantity  that  must  be  used,  since 
an  inadequate  d(jse  of  the  radiation  merely  stimulates  a  new  growth  to 
more  rapid  proliferation.  As  the  power  of  the  ray  diminishes  as  the 
square  of  the  distance  from  the  radium,  it  necessarily  follows  that  the 
tissues  to  be  acted  upon  must  be  as  close  as  possible,  and  wherever  it  can 
be  so  arranged,  the  neoplastic  tissues  should  be  in  contact  with  the 
radium  container,  while  normal  tissues  should  be  at  as  great  a  distance  as 
possible.  When  we  have  to  deal  with  a  large  cancer  surrounding  the 
esophagus,  as  shown  .schematically  in  Fig.  3!t."),  there  is  no  doubt,  as  deter- 
mined by  biopsy  by  Dr.  Andrews  in  consultation  with  the  author,  that 
the  periphery  of  the  growth,  as  shown  at  P,  is  stimulated  by  the  atten- 
uated ray  that  is  able  to  reach  it  through  the  thickness  of  the  tissue  M. 
The  tissues,  H,  in  contact  with  the  tube,  R,  should  be  (|uickly  melted 
away  by  large  dosage  in  order  to  reach  the  peri|)heral  cells  shown  at  P, 
before  the  latter  have  had  too  long  a  time  to  develi)]).  In  the  endoscopic 
application  of  radium,  to  obtain  results  it  is  necessary  to  use  large  dosage 
for  a  less  time  rather  than  a  less  dosage  for  a  longer  time,  because  of  the 
discomfort  of  any  esophageal  application.  I'.y  either  the  larger  or  the 
smaller  dosage  i)lan,  it  is  necessary  that  such  a  degree  of  radio-activity 
be  developed   that   it   is  unwise  to  have   the   container  in   contact   with 


454 


MALIGNANT  niSICASIC   dl"  'I'lIF.    USOPIIAGUS. 


healthy  tissue.  In  esophageal  work  the  only  way  to  be  sure  that  the 
container  is  in  contact  with  neoplastic  tissue,  and  no  other  is  to  do  the 
work  esophagoscopically  and  to  see  that  the  container  is  placed  precisely. 
The  only  way  to  make  sure  that  the  container  remains  where  placed,  is  to 
see  that  it  is  in  place  by  frequent  inspection.  ^\'ith  all  forms  of  blind 
introduction  there  is  an  uncertainty  that  renders  safety  of  radium  treat- 
ment questionable.  It  has  been  suggested  that  a  watch  on  the  position  of 
the  capsule  be  kept  by  the  fluoroscopic  screen  with  roentgen  ravs.  The 
esophagoscope  having  been  removed,  the  replacement  of  the  capsule,  if 
found  displaced,  is  to  he  made  bv  a  rigid  wire  carrier  attached  to  the 


F'G.  395.^Schematic  representalion  of  a   radium  capsule  in  the   center  of   an 
annular  esophageal  cancer. 


capsule.  This  is  objectionable  because  of  its  inaccuracy,  the  exact  posi- 
tion of  the  stricture  not  being  \isible  fluoroscopically  without  bismuth  : 
and  especially  because  it  prevents  the  use  of  the  flexible  joint  so  necessary 
for  accurate  applications  to  deviated  luniina. 

The  author's  method  is  as  follows :  The  radium  salt  used  is  con- 
tained in  a  very  small  glass  capsule,  and  this  capsule  is  contained  in  a 
metal  capsule  •'>  mm.  in  diameter,  the  wall  of  the  capsule  being  0.3  mm.  in 
thickness.  Outside  it  is  covered  with  a  coating  of  hard  rubber  vulcan- 
ized on  (M,  Fig.  397).  This  silver  capsule  has  a  solid  ring  or  eye  in 
one  end.  A  long  extra  drainage  tube  (B,  Fig.  39ti),  which  was  used  by 
the  author  in  his  early  work  for  aspirating  secretions  from  the  bronchi 


MAMCNAXT  DISK  VSE   01"  TIIK    KSOPIIAGUS. 


455 


before  he  perfected  his  "sponge-pumping"  metiiod,  was  found  to  make 
the  best  possible  carrier  of  the  utmost  simplicity.  A  small  wire  is 
passed  through  the  aspirating  tube  and  brought  out  at  the  distal  end.  .\ 
loop  of  heavy  braided  silk  (not  twisted  silk)  is  attached  to  the  wire,  and 
the  silk  is  thus  drawn  through  the  tube.  To  the  silk  at  the  distal  end, 
the  capsule  is  attached  by  means  of  a  loop  (P),  formed  with  a  bow  knot, 
as  shown  in  Fig.  .'590.  Xow  by  drawing  the  silk  taut,  and  making  it  fast 
around  the  shoulder  of  the  proximal  end  of  the  drainage  tube,  the  cap- 
sule is  brought  firmly  into  the  end  of  the  drainage  tube,  but  not  so  firmly 
but  that  lateral  inovement  is  pos^^ible.       This  makes  a  stifif  joint  at  the 


Fig.  396. — Author's  method  of  applying  radium  endoscopically. 


point  where  the  eye  of  the  capsule  is  drawn  into  the  end  of  the  drain 
age  tube,  motion  being  i)ermitte(l  as  shown  by  the  dotted  line. 
For  the  esophagus  a  drainage  tube  of  lii)  cm.  is  used,  and  for  the 
larynx,  a  .'id  cm.  length  is  sufficient,  though  one  of  40  cm.  would  be 
needed  f(jr  the  bronchi.  Any  one  who  does  not  have  the  drainage  tube 
can  get  the  proper  length  of  brass  tubing  of  .i  mm.  external  diameter 
from  any  instrimient  maker.  The  piu-pose  of  the  movement  permitted  by 
the  joint,  is  to  allow  the  capsule  to  be  placed  flatwise  when  the  axis  of 
application  does  not  correspond  witli  the  axis  of  the  endoscopic  tube. 
Thus  in  treating  the  laryngeal  case  before  mentioned,  Dr.  Patter- 
son made  the  application  by  placing  the  capsule  along  the  entire  length 


456  MALIGNANT  DISEASE  OF  THE  ESOPHAGI'S. 

of  the  aryepiglottic  fold,  which  would  have  been  impossible  had  the  con- 
tainer been  rigidly  held  in  any  form  of  carrier.  In  the  use  of  forceps, 
there  is  always  the  possibility  of  the  capsule  getting  lost  trom  the  grasp 
of  the  forceps  during  the  manipulation,  and  such  an  accident  might  be 
exceedingly  serious,  because  if  not  immediately  recovered  the  prolonged 
activity  of  the  radium  would  certainly  be  fatal.  For  this  reason  also,  the 
braided  silk  used  should  be  thoroughly  tested.  The  first  two  or  three  ap- 
plications in  each  case  should  be  made  with  the  esophagoscope  in  situ  for 
the  entire  time  in  order  to  see  whether  the  container  is  moved  by  re- 
gurgitant or  other  movements.  For  this  purpose  the  esophagoscope 
should  be  covered  with  hard  rubber  vulcanized  on  (Fig.  397)  in  order 
to  prevent  irritant  secondary  rays.  The  esophagoscope  and  radium  con- 
tainer in  situ  in  the  living  patient  are  shown  in  Figs.  398,  399,  4()0,  401  and 
402.     \\"hen  satisfied  that  the  radium  capsule  will  stay  where  placed  the 


Fig.    397. — Esophagoscopes    with    hard    rubber    screens    vulcanized    on,    to    cut 
down  irritating  secondary  radiations. 

silk  may  be  untied  from  the  proximal  end  of  the  drainage  tube  and  the 
esophagoscope  and  drainage  tube  may  both  be  withdrawn  leaving  the 
capsule  in  situ  with  only  a  string  for  later  withdrawal  (Fig.  400). 
Anesthesia  is  not  necessar}'.  The  best  position  of  the  patient  for  radium 
applications  to  the  esophagus  with  the  esophagoscope  in  situ  is  the  re- 
cumbent, because  the  esophageal  drainage,  already  defective,  is  occluded 
by  the  radium  container,  the  hypopharynx  fills  and  the  overflow  into  the 
larynx  excites  constant  cough  and  strangling,  which  makes  a  very  trying 
ordeal  for  the  patient.  In  the  recumlient  position  the  secretions  all  flow 
into  the  fauces  and  are  aspirated  through  the  tube.  Fig.  24.  attached  to 
the  aspirator,  Fig.  23.  When  the  radium  container  is  left  in  situ  and  the 
esophagoscope  is  withdrawn  the  patient  may  lie  face  sidewise  on  the 
table  to  permit  secretions  to  drain  away. 

Dosage  is  dependent  on  duration  of  the  applications.    The  equivalent 
of  !I00  milligrams  of  radium  element  well  screened  may  be  left  in  situ 


MALIGNANT  DIS1■;.\^I■:   Ol"  TIIIC    K.SOl'llAGUS. 


457 


Fic.  398 — Radium  container  in  situ  in  a  case  of  esophageal  cancer.  The  ex- 
cessive forward  inchnation  of  the  capsule  is  partly  due  to  malignant  distortion. 
(The   normal   esophagus  tends  somewhat    forward   in   this   location). 


Fir..  399. — Radium  capsule  in  place  in  a  case  of  esophageal  cancer.  The  esoph- 
agoscopc,  screened  with  hard  ruhber,  is  kept  in  situ  to  watch  the  position  of  the 
capsule  until  certain  it  will  not  shift. 


458 


MALIGNANT  DISEASE  OF  THE    ESOPHAGUS. 


for  two  or  three  hours,  the  applications  being  repeated  on  alternate  days 
for  about  ten  applications.  If  excessive  local  reaction  or  general  tox- 
emia result  the  treatment  should  be  interrupted  for  a  few  weeks.  These 
dosages  are  given  with  reservations.  The  future  may  determine  them  to 
be  too  large  or  too  small.  Mr.  ^Valter  G.  Howarth  has  been  getting  ex- 
cellent results  from  the  use  of  100  mgm.  kept  in  situ  by  means  of  a  wire 


Fig,  400. — Radium   container   in   situ  in  a  case   of  esophageal   malignancy, 
stout  braided  silk  cord  is  attached  to  the  eye  but  does  not  show. 


brought  out  through  the  mouth,  for  a  (leriod  of  eight  hours  and  has  re- 
peated the  application  twice  or  three  times  at  inter\als  of  a  few  days. 
Local  reaction.  The  first  effect  noted  is  not  usually  seen  until  after 
a  few  applications.  Then  the  perimalignant  inflammatory  zone  is  seen 
to  have  disappeared.  The  lumen  through  the  growth  increases  in  size 
and  fungations  diminish.  If  the  dosage  is  excessive  or  if  not  well 
screened,  inflammation  with  sloughing,  and  with  exfoliation  of  epithelium 
from  the  normal  mucosa  mav  be  noted. 


MALKiNAN'l"   IHSI'.ASI-:    Ol'   T  H  K    i:SOI' 1 1 AGUS. 


459 


Fig.   401. — Radio.q^raph    nf    radium   container   in    situ    showing    fogging   of   the 
plate  by  tile   n'.dium   rax  s,   iu   nine  minutes  exposure. 


Flc.  402. —  Peroral   radium   ai)plie;'tion   to  cancer  of  tlie  car<lia. 


CHAPTER     XXVIII. 

Direct  Laryngoscopy  in  Diseases  of  the  Larynx. 

For  diagnostic  purposes  the  greatest  usefulness  of  the  direct  method 
has  been  in  the  laryngeal  diseases  of  children,  a  field  which  prior  to  the 
development  of  direct  laryngoscopy  could  not  be  studied  in  the  living. 
For  treatment,  especially  surgical  treatment,  the  direct  method  has  placed 
endolaryngeal  surgery  on  a  plane  impossible  of  attainment  by  indirect 
methods. 

Endoscopic  appearances  of  laryiujcal  disease.  The  appearance  of 
the  mucosa  as  to  color,  edema,  ulceration,  infiltration  and  neoplastic  pro- 
cesses is  so  fully  studied  in  books  on  laryngology  that  extensive  consid- 
eration here  is  needless.  Besides  the  difference  in  form  due  to  the  point 
of  view  previously  referred  to,  only  one  point  need  be  mentioned,  name- 
ly, the  wide  variations  in  color  due  to  engorged  vascularit\-  induced  re- 
flexly  by  the  presence  of  the  direct  laryngoscope  so  close  to  the  laryngeal 
orifice.  As  elsewhere  explained,  this  engorgement  varies  with  the  anes- 
thetic used,  and  is  usually  greater  when  no  anesthetic  at  all  is  used  for 
the  examination.  It  is  always  wise,  therefore,  to  get,  in  the  first  view, 
an  accurate  estimate  of  color.  If  covered  with  a  mask  of  secretion  this 
must  be  quickly  and  gently  wiped  away  after  the  first  inspection. 

Subglottic  edema.  This  has  been  previously  referred  to.  liecause 
of  the  easily  elevated  mucosa  and  the  abundant  submucosal  cellular  tis- 
sue it  is  often  the  first  indication  of  perichondritis.  \Vhen  the  latter  has 
been  cured,  a  chronic  edema  or  hyperplasia  should  be  cauterized  as  shown 
in  Fig.  87. 

Perichondritis,  abscess  and  their  sequelae  are  easilv  diagnosticated 
and  treated  in  children  on  well  known  principles.  Stenosis  following 
these  conditions  is  the  subject  of  a  separate  chapter. 

Tuberculosis.  The  author  is  in  accord  with  Kahler.  who  states 
that  indiscriminate  surgical  treatment  of  the  tuberculous  larynx  is  a  mis- 
take and  has  led  to  discredit,  whereas  proper!}-  planned  surgical   meas- 


DIRECT  LARYNGOSCOPY  IN  DISEASES  OF  THE  LARYNX.  4(jl 

iircs  in  selected  cases  have  yielded  excellent  results.  As  stated  by  Mr. 
Uavis  (Bib.  100) — "When  the  larynx  is  involved  a  vicious  circle  oc- 
curs, in  which  the  dysphagia,  sleeplessness,  and  cough  produced  by  the 
painful  lesion  markedly  increase  the  rapidity  of  the  progression  of  the 
lung  condition.  The  judicious  removal  by  surgical  methods  of  painful 
lesions  undoubtedly  relieves  jiain,  and  vig(jrous  methods  with  careful  re- 
search are  needed  to  attack  the  much-dreaded  laryngeal   tuberculosi.s." 

Extirpation  of  tuberculous  laryngeal  lesions.  When  small  and  iso- 
lated, extirpation  of  the  entire  lesion  may  _\ield  excellent  results  as  in 
the  following  case : 

A  girl  of  eighteen  years,  referred  by  Dr.  !',.  L.  Calhoun  for  increas- 
ing hoarseness  of  some  months'  duration.  Indirect  larj-ngoscopy  showed 
a  small  projection  from  the  right  cord  (A,  Fig.  403)  which  looked  like 


Fig.  40,3. — Case  of  extirpation  of  a  small  isolated  laryngeal  tiilifrcuknis  nodule, 
in  a  girl  of  eighteen  years.  .\  Growth  on  right  cord  thought  to  be  of  inllamma- 
tory  origin  hut  later  proven  tuberculous.  B.  One  week  after  e.xtirpation  the  cord 
on  the  operated  side  does  not  seem  to  be  drawn  tense  in  attempted  phonation. 
C.  Two  weeks  after  operation  phonation  is  perfect.  D.  Larynx  on  inspiration 
live  years  after  operation. 

a  singer's  node.  As  a  rule  the  author  does  not  favor  the  removal  of 
singer's  nodules,  but  as  this  was  one-sided  and  was  clearly  the  cause  of 
the  hoarseness,  the  author  yielded  to  the  patient's  demand  that  the  growth 
he  excised  in  order  to  restore  the  voice  promptly  to  enable  the  patient 
to  finish  her  year's  contract  as  a  singing  teacher.  The  growth  was  re- 
moved by  direct  laryngoscopy  with  very  hapi)y  results  as  regards  voice. 
Dr.  Ernest  W.  Willetts  reported  the  growth  to  be  undoubtedly  tuber- 
culous. This  diagnosis  was  subsetiuently  confirmed  by  physical  exam- 
ination and  by  the  finding  of  bacilli  in  llie  sjiutuni,  which,  of  course,  came 
from  the  [lulmonary  lesion.  Rest  in  bed,  oi)en  air  and  a  complete  anti- 
tuberculous  regime  under  the  skillful  care  of  Dr.  Calhoun  entirely  cured 
the  pulmonary  condition,  and  now,  five  years  later,  the  patient's  larynx 
is  as  shown  at  D  in  Fig.  in:;,  entirely  and  comi>letely  well.  This  case 
illustrates  clearly  what  may  be  done  by  direct  laryngoscopic  excision  of 


462  DIRECT  LARYNGOSCOPY  IN  DISEASKS  OF  THE  LARYNX. 

tuberculous  growths.  Manifestl}',  however,  it  is  ouly  adapted  to  isolated 
foci  and  is  not  to  be  applied  to  the  usual  massive  arytenoid  infiltrations. 
Diffuse  infiltrations  are  not  amenable  to  extirpation,  but  encroachments 
on  the  glottis  may  be  removed  with  great  relief  of  dyspnea  and  secondary 
benefits  from  improved  oxidation. 

Amputation  of  the  cpic/lottis.  Tuberculosis  of  the  epiglottis  may 
prove  one  of  the  most  disastrous  lesions  that  a  tuberculous  patient  can 
develop,  not  so  much  from  the  toxemia  of  the  lesion  itself  as  from  the 
odynphagia  which  interferes  very  seriously  with  the  patient's  nourish- 
ment ;  and,  unfortunately,  nearly  all  the  applications  that  can  be  made  to 
lessen  the  pain  of  swallowing  interfere  with  the  appetite  so  that  food  is 
not  relished,  and  even  nausea  and  vomiting  may  be  induced.  If  ampu- 
tation of  the  epiglottis  is  necessary,  it  is  very  easily  accomplished  by  the 
method  gi\en  in  Chapter  \TI. 

Gak'ono puncture  for  laryngeal  tuberculosis.  Of  the  endoscopic 
surgical  methods  galvano-puncture  will  soon  be  entitled  to  first  place 
since  the  advantages  of  its  endoscopic  use  have  been  demonstrated.  Deep 
puncture  produces  the  best  results  in  infiltrations  without  ulceration,  but 
it  is  necessary  to  avoid  punctr.ring  the  arytenoid  joint.  Next  to  these, 
fungating  ulcerations  are  most  amenable.  The  fungalions  after  a  single 
application  will  often  disappear  and  the  ulcer  will  cicatrize.  For  ulcera- 
tion superficial  cauterizations  are  preferable.  In  difi^used  edematous  in- 
filtrations deep  punctures  are  to  be  preferred.  Llcerative  tuberculosis 
of  the  epiglottis  and  lesions  involving  the  posterior  surface  of  the  ary- 
tenoid and  mouth  of  the  esophagus  yield  readily  to  cauterant  treatment. 
Excessive  reaction  sometimes  follows  the  application  of  the  galvano- 
cautery,  though  rarely.  It  is  best  to  make  only  a  slight  application  at 
first  to  see  how  much  reaction  the  particular  individual  will  probably 
manifest.  Deep  punctures  at  a  white  heat  produce  less  reaction  than 
superficial  punctures  or  those  made  at  a  dull  red  heat.  Perichondritis 
has  followed  in  some  instances,  but  as  this  is  quite  a  usual  complication  in 
tuberculosis  of  the  larynx  it  cotild  not  be  determined  in  any  of  the  cases 
reported  in  the  literature  that  the  [lerichondritis  resulted  directly  from 
the  cautery.  They  woukl  ])rohably  have  occurred  anyway  from  the 
mixed  infections  at  work  in  ulcerated  areas.  The  technic  of  galvano- 
puncture  is  alluded  to  under  the  head  of  direct  laryngoscopy. 

CO\GENIT.\L  L.VRYNGEAL  STRinOR. 

Stridorous  breathing  may  be  due  to  aii\-  one  of  many  dift'erent  forms 
of  obstruction  of  the  larynx  and  trachea.  The  text  books  mention  tradi- 
tional sounds,  signs  and  symptoms  by  which  it  was  thought  distinctions 
might  be  made  as  to  the  different  locations  affected.     To  reiterate  these 


DIRECT  I.ARVNCOSCOPV  IN  DISEASES  Ol'   Tin;   LAin.W.  463 

would  be  useless.  A  diagnosis  based  upon  anything  but  looking  and  see- 
ing is  wrong  as  often  as  right.  Many  different  conditions  were  supposed 
to  exist  to  account  for  the  symptoms  of  stridor  coming  on  at  or  shortly 
after  birth  and  continuing  for  a  year  or  two.  Many  of  these  hypotheses 
doubtless  applied  to  conditions  which  really  e.xist  in  some  cases,  but  it 
seems  best  to  limit  the  name  to  those  cases  of  exaggerated  infantile  type 
of  larynx,  as  described  by  D.  R.  Paterson,  A.  Brown  Kelly,  G.  A.  South- 
erland  and  H.  L<ambert  Lack.  Sir  St.  Clair  Thompson's  description  (Bib. 
539)  is  excellent.  "The  epiglottis  is  very  long  and  tapering,  and  its 
lateral  margins  are  rolled  backward  so  as  to  meet,  and  thus  form  a  com- 
plete cylinder  above.  The  greatly  reduced  entrance  to  the  larynx  is 
bounded  by  the  aryepiglottic  folds  which  are  too  closely  opposed  to  admit 
any  but  the  slightest  amount  of  air.  The  croaking  noise  is  caused  by  the 
free  and  unsupported  part  of  the  posterior  laryngeal  wall  and  neighb(jring 
loose  tissue  on  the  summits  of  the  arytenoids  which  is  sucked  forwards 
and  inwards  during  inspiration."  This  description  coincides  with  three 
cases  seen  by  the  author,  one  of  which  is  illustrated  at  D,  in  Fig.  93. 
The  endoscopic  picture  varied  slightly  in  the  different  cases,  but  the  es- 
sential form  of  the  exaggerated  infantile  type  was  present.  The  author 
has  seen  a  case  of  congenital  stridor  from  other  causes.  One  caused  by 
papilloma  was  probably  congenital,  and  one  was  certainly  congenital.  A 
marked  inspiratory  stridor  in  another  case  was  found  to  be  due  to  the 
collapse  of  the  posterior  membranous  tracheo-esophageal  wall  into  the 
trachea  as  a  result  of  the  negative  pressure  in  inspiration.  This  collapse 
occurs  normally  to  some  extent  in  breathing  and  markedly  in  coughing 
but  not  so  markedly  as  seen  in  this  case.  It  was  an  exaggerated  form  of 
the  forward  movement  of  the  posterior  tracheal  wall  seen  in  Fig.  144. 
In  one  case  of  thymic  stenosis  the  stridor  was  marked  but  was  of  a  less 
croaking  character  than  in  the  purely  laryngeal  form.  In  a  number  of 
cases  spasm  was  present  in  infants  with  the  history  of  stridor  having 
been  present,  "ever  since  they  were  born,"  but  as  mentioned  above,  the 
author  considers  it  best  to  limit  the  name  congenital  laryngeal  stridor 
to  the  anomalous  exaggerated  infan.tile  larynx.  The  diagnosis  is  very 
readily  made  in  a  few  seconds  by  the  aid  of  the  direct  laryngoscope  with- 
out any  anesthesia,  general  or  local.  In  regard  to  treatment,  direct 
laryngoscopy  has  nothing  to  offer  save  that  should  asphyxia  threaten,  a 
bronchoscopy  would  sustain  life  initil  a  tracheotomy  could  be  done.  .\s 
a  matter  of  fact,  however,  the  author  has  never  seen  a  case  where  the 
symptoms  were  sufficiently  urgent  to  demand  this.  If.  however,  the  pa- 
tient has  a  history  of  \ery  severe  suffocative  attacks  with  cyanosis  and 
is  not  so  situated  that  immediate  tracheotomy  can  lie  done,  doubtless  it 
would  be  very  much  safer  to  have  the  tracheotomj'  done  as  a  preventive 


464  DIRECT  LARYNGOSCOPY  IN  DISEASES  OF  THE  LARYNX. 

measure.  All  of  the  author's  cases  recovered  completely  within  a  year 
by  attention  to  the  general  health  and  especially  careful  feedings  carried 
out  by  the  medical  attendant. 

Congenital  zvcbs  of  the  laryn.v  and  doubtless  other  malformations 
may  produce  stridor.  ()ne  interesting  case  of  the  author  is  illustrated  in 
Fig.  9-i.  At  C  is  seen  a  tumor-like  mass  bulging  upward  from  the  vocal 
cords  of  a  child  three  months  of  age,  which  had  had  a  crowing  inspiratory 
stridor  since  birth.  The  child  was  crying  at  the  moment  represented  by 
the  sketch.  Almost  immediately  afterwards  the  child  took  a  deep  breath 
and  what  seemed  to  be  a  tumor  was  now  very  plainly  seen  to  be  a  web 
stretching  across  from,  one  vocal  band  to  the  other,  and  while  it  seemed 
slightly  below  the  cord  in  this  position  yet  on  phonation  the  band  folded 
upward  into  the  tumor-like  mass  seen  at  C,  Fig.  94. 

Congenital  goitre  and  congenital  laryngeal  paralysis  of  each  of 
which  the  author  has  seen  one  case,  may  cause  congenital  stridor  but 
these  are  better  considered  under  stenosis. 


CHAPTER     XXIX. 

Bronchoscopy  in  Diseases  of  the  Trachea 
and  Bronchi. 

The  field  opened  up  liy  Killian's  demonstration  of  the  ease  and  harm- 
lessness  of  a  careful  bronchoscopy  is  so  enormous  and  so  new  that  thor- 
ough, sxstematic,  analytical  consideration  of  it  at  the  present  time  is  im- 
possible. Unfortunately,  the  trachea  is  a  border  line  organ  to  which 
heretofore  relatively  little  attention  has  been  given.  The  laryngologist 
could,  with  his  mirror,  see  a  little  of  the  upper  portion  but  he  seldom  at- 
tempted much  in  the  way  of  study  or  treatment.  The  internist  was  more 
interested  in  the  deeper  air  passages  and  touched  lightly  upon  it  as  of 
little  importance.  The  general  surgeon  rarely  operated  upon  it  except 
to  open  it  in  tracheotomy  or  to  amputate  it  in  laryngectomy.  The  direct 
method,  however,  has  opened  up  a  new  field  of  study  and  the  trachea 
and  its  diseases  will  be  systematically  dealt  with  in  the  laryngologic  text 
books  of  the  future.  Delavan  has  called  attention  to  the  fact  that  the 
earliest  use  of  a  direct  method  of  endobronchial  medication  was  carried 
out  by  Horace  (jreen  in  18U,  whose  results  were  published  in  bonk  form 
in  LSKI. 

Iitdications  for  bronchoscopy  in  disease.  Various  indications  may 
be  gathered  from  the  hereinafter  mentioned  bronchoscopic  observations 
in  the  various  diseases.  But  it  may  be  well  to  emphasize  a  few  of  the 
most  clearly  defined  and  urgently  important  indications. 

I.  .All  cases  of  bronchiectasis  should  be  bronchoscoped  for  foreign 
bodies,  for  diagnosis  and  also  for  local  treatment.  Emil  Mayer  found  a 
foreign  body  in  one  case  of  bronchiectasis  where  its  presence  had  never 
been  suspected.  The  author  has  foimd  bronchiectasis  present  in  two 
cases  of  prolonged  sojourn  of  a  foreign  body  in  the  right  inferior  lobe 
bronchus,  though  in  botii  of  these  cases  the  foreign  body  had  been  dis- 
covered radiographically. 

5.  Every  case  of  dyspnea,  except,  of  course,  pneumonia  and  similar 
well   understood  conditions,  calls  for  bronchoscopy. 


466  BRONXHOSCOPY  IX  DISEASFS  OF  TRACHKA  AND  BRONCHI. 

3.  Every  case  in  which  tracheotomy  does  not  reheve  the  dyspnea 
should  be  bronchoscoped  to  determine  why  the  tracheal  cannula  does  not 
give  relief. 

4.  All  cases  of  hemoptysis  which  are  not  definitely  proved  to  be 
tuberculous  should  be  bronchoscoped  for  diagnosis,  and  any  severe 
bleeding  may  be  endoscopically  packed  as  advised  by  Killian. 

5.  Even,'  case  of  paralysis  of  the  recurrent  nerve  the  cause  of 
which  is  not  positively  known,  calls  for  bronchoscopy. 

G.  In  any  case  of  thoracic  disease  in  which  any  element  of  doubt 
exists,  valuable  information  may  be  gained  by  bronchoscopy. 

7.  In  case  of  doubt  as  to  whether  bronchoscopy  should  be  done  or 
not,  bronchoscopy  should  always  be  done. 

Contra'mdkaiions  to  broiichoscof^y  in  disease.  The  author  cannot 
recall  any  absolute  contraindication  to  a  careful  bronchoscopy  in  any 
case  in  which  it  is  really  needed.  Unless  there  are  urgent  indications, 
however,  it  had  better  not  be  done  except  for  foreign  bodies,  in  case  of 
aneurysm,  high  blood  pressure,  advanced  heart  disease,  pulmonary  tuber- 
culosis. There  are  no  valid  contraindications  whatsoever  to  bronchos- 
copy in  any  case  of  obstructive  dsypnea,  provided,  of  course,  the  bron- 
choscopist  is  prompt  and  certain  in  his  insertion. 

Anesthesia.  Xo  anesthesia  is  needed  in  children.  In  adults  local 
anesthesia  of  the  lar)-nx  is  needed.  Below  this,  for  scientific  study,  it  is 
advisable  to  make  at  least  one  examination  without  any  anesthesia,  gen- 
eral or  local,  because  of  the  alteration  of  the  picture  by  anesthesia.  For 
applications  to  the  tracheo-bronchial  tree  mo-^t  operators  make  an  ap- 
plication of  a  local  anesthetic  to  the  larynx.  For  this  purpose,  cocaine 
is  used  by  practically  all  endoscopists.  If  applications  have  to  be  fre- 
quently made,  the  author  would  urge  the  use  of  extremely  diluted  solu- 
tions and  the  trial  of  other  local  anesthetics  and  of  no  anesthetic.  In  no 
case  should  the  patient  know  the  drug  used  for  anesthesia.  Additional 
consideration  of  this  subject  will  be  found  in  Chapter  I\'. 

Position  of  the  patient.  The  recumbent  position  is  best  for  chil- 
dren ;  the  sitting  position  for  adults.  For  examination  of  a  \ery  dyspneic 
patient,  such  as  an  asthmatic  during  an  attack,  the  sitting  ]iosition  will 
cause  the  patient  less  distress,  though  for  obtaining  scientific  data,  it 
would  be  well,  when  possible,  to  examine  the  jiatient  in  both  the  sitting 
and  the  recumbent  posture.  For  endobronchial  applications,  the  patient 
should  be  in  the  sitting  position  in  order  to  get  the  assistance  of  gravity 
in  diftusing  the  medication.  For  removal  of  excessive  secretions  "sponge- 
pumping"  in  the  recumbent  posture  is  most  promptly  efficient.  (For  full 
consideration  of  position  see  Chapter  VI,) 


BKOXCIIOSlOl'V  IX   DISKASKS  OF  TRACHKA   AM)  I'.KONCIir.  407 

Bronchoscopk  appearances  in  disease.  The  variations  of  mucosal 
color  in  health  in  difl'erent  individuals  and  as  influenced  liy  general  and 
local  anesthesia,  degree  of  ilhiniination.  tubal  contact,  a  him  coating  of 
secretions,  et  cetera,  as  considered  in  Cha])ter  IX.  must  be  borne  in  mind 
in  endoscopy  for  disease.  The  first  look  should  com[)rehend  the  color  as 
accurately  as  possilile  over  the  entire  visible  area.  With  proper  illu- 
mination the  ap|)earances  in  disease  are  readily  recognized  ])y  the  rhino- 
laryngologist  who  is  familiar  with  the  appearance  of  various  mucosal 
pathologic  changes.  To  appreciate  morbid  departures  in  form,  it  is 
necessary  to  he  familiar  with  the  normal  as  seen  under  widely  varying 
conditions  of  age,  movement,  cough,  etc.  Bronchoscopists  have,  in  the 
variations  of  the  form  and  movement  of  the  bifurcation,  a  very  valuable 
means  of  contributing  to  the  diagnosis  of  intrathoracic  disease.  The 
carina  trachealis  in  the  normal  chest  moves  forward  as  well  as  down- 
ward during  deep  inspiration,  returning  on  expiration.  The  auiiior  has 
noticed  in  addition  to  the  above  mentioned  observation  of  Gottstein,  that 
the  descent  on  deep  inspiration  is  slow  as  compared  to  the  quick  return 
in  the  following  expiration,  and  furthermore,  after  the  return  there  is  a 
distinct  interval  of  repose  which  is  longer  thau  tlie  normal  repose  of 
rhythmic  respiration.  To  note  this  movement,  it  is  necessarv  that  the 
bronchoscope  shou'd  not  be  too  near  the  bifurcation,  as  the  instrument 
itself  will  resist  movement  to  a  great  extent.  This  normal  respiratory 
movement  of  the  carina  is  of  great  diagnostic  importance  because  it  is 
interfered  witii  liy  various  peri-tracheal  and  peri-bronchial  conditions. 
The  fixation  is  .'.;reatest  in  cancer,  somewhat  less  so  in  case  of  masses  of 
tuberculous  glands  unless  these  have  sup])urate(l,  and  the  movement  is 
only  slightly  interfered  with  in  aneurysm.  In  fact,  it  is  not  usually  no- 
ticeable at  all,  unless  the  aneurysm  is  of  enormous  size. 

Rxploration  of  the  upper  lobe  bronchus  is  limited  to  the  orifice  and 
a  short  portion  of  its  stem,  Init  useful  information  may  be  gained  from 
the  secretions  seen  to  emerge. 

lindobronchial  treatment.  Ingals  wisely  advises  caution  in  the  de- 
velopment of  endobronchial  th.crapy.  As  pointed  out  by  Kphraim  and 
others,  ordinary  oral  inhalations  of  nebulized  fluids  are  practically  worth- 
less for  the  local  treatment  of  disease,  for  the  reason  that  the  nebula 
does  not  penetrate  even  as  far  as  the  trachea.  This  has  lieen  proven  ex- 
perimentally on  animals.  Even  where  all  the  air  inhaled  by  the  patient 
is  saturated  with  finely  nebulized  fluid,  it  is  doubtful  whether  any  ap- 
preciable amount  reaches  the  deeper  air  passages,  because  of  the  im- 
pinging upon  the  mucosa  at  the  various  turns  of  the  upper  air  passages. 
These  various  surfaces  act  as  bafTle  jilates  to  remove  the  minute  particles 
of  medication  suspcnderl  in  the  air.     Intratracheal  injections  with  tlie  aid 


4(iS  BRONCHOSCOPY  IN  DISEASES  OF  TRACHEA  AND  BRONCHI. 

of  indirect  lan'ngoscopy,  have  slightly  better  resuhs,  but  even  then  the 
])rompt  coughing  of  the  patient  will  remove  the  fluid  before  it  can  reach 
the  deeper  passages,  even  when  a  large  quantity  of  fluid  is  thrown  in, 
though  of  course  the  larger  the  quantity  the  greater  the  likelihood  of  its 
reaching  the  bronchi.  On  the  other  hand,  endoscopic  applications  place 
the  fluid  deep  down  in  the  bronchi,  where  all  bechic  eftorts  to  expel  it 
only  serve  the  better  to  scatter  it  over  the  mucosa.  The  most  commonly 
used  method  is  with  the  endoscopic  syringe  with  long  metal  nozzle  in- 
serted through  the  bronchoscope.  Dr.  Emma  E.  Musson  of  Philadel- 
phia, has  been  using,  with  excellent  results,  a  method  which  she  demon- 
strated before  the  meeting  of  the  Pennsylvania  State  Medical  Society 
(Bib.  401).  The  larynx  is  exposed  with  the  laryngoscope.  A  little  of  a 
local  anesthetic  solution  is  applied  to  the  interior  of  the  larynx,  and  a 
long  silk-woven  tube  is  passed  through  the  larynx  down  into  the  bronchi. 
The  medicated  solution  is  then  injected  with  a  syringe,  the  short  nozzle 
of  which  is  inserted  firmly  into  the  proximal,  funnel-like,  silk-woven 
tube.  The  placing  of  the  head  to  one  side  will  insure  the  silk-woven  tube 
going  into  the  opposite  bronchus,  especially  if  a  little  curve  is  imparted 
to  the  tube  before  insertion.  This  method  seems,  to  the  author,  the  very 
Ijest,  because  the  application  can  be  made  with  accviracy  and  with  very 
slight  annoyance  to  the  patient.  Of  course,  skill  is  required  to  be  certain 
of  the  accurate  placing  of  the  silk-woven  tube  in  the  desired  bronchus. 

Anomalies  of  the  tracheobronchial  tree.  Anomalies  of  the  tracheo- 
bronchial tree  are  rare,  but  variations  from  what  might  be  con- 
sidered as  an  average  type  are  noted  by  every  endoscopist.  Kahler  (Bib. 
300)  reports  two  cases  of  diverticulum  of  the  tracheobronchial  tree 
consisting  of  rudimentary  Ijronchial  branches.  Guisez  reports  a  con- 
genital valve-like  web  obstructing  part  of  the  trachea.  The  dyspnea  was 
relieved  by  incision  and  dilatation.  Congenital  esophagobronchial  and 
esophagotracheal  fistulae  have  been  reported. 

Deviation  of  lite  trachea  and  laryngo ptosis.  An  interesting  obser- 
vation of  the  author  is  the  coincidence,  in  two  cases,  of  deviation  of  the 
trachea  with  laryngoptosis.  The  author  has  seen  a  third  case  of  laryn- 
goptosis  which  also  had  a  deviated  trachea,  but  this  was  a  case  of  can- 
cer. .\s  there  was  compression  of  the  trachea,  as  well  as  deviation,  by  a 
mass  probably  of  infected  mediastinal  lymph  nodes  with  involvement  of 
the  esophageal  wall,  there  could  be  no  certainty  that  there  had  been  a 
previously  existing  deviation  of  the  trachea.  One  case  of  deviation  with 
laryngoptosis  with  cervical  ribs  was  reported  (Bib.  2()9,  pp.  77,  7'8  ).  The 
second  patient  was  a  woman  of  32  years  of  age  who  came  to  the  dis- 
pensar}'  for  acute  laryngitis,  which,  however,  seemed  to  be  in  no 
way  connected  with   the  ptosis  of  the  larynx.     The   woman  had  never 


nuO.NCIIOSCOI'Y  IN  DISEASES  OF  TRACHEA   AND  BKONCIII. 


■iGi) 


noticed  llial  her  "Adam's  ai)]>le"  was  any  lower  llian  in  other  people. 
She  had  heen  subject  to  dyspnea  on  exertion  ever  since  she  could  re- 
member; but  had  not  been  particularlv  subject  to  attacks  of  hoarseness, 
such  as  that  caused  by  the  acute  laryngitis  for  the  relief  of  wdiich  she 
applied.  .A  bronclioscopy  under  local  anesthesia  showed  the  trachea  de- 
viated sharply  backward,  as  shown  at  D,  in  diagram  C,  Fig.  404.  The 
patient  was  sent  to  Dr.  Russell  H.  Boggs  for  a  radiograph  of  the  chest, 
but  tinfortunately  she  did  not  go  and  disappeared,  no  trace  of  her  being 
obtainable  at  the  address  gi\en  on  the  dispensary  register.  All  three  of 
these  cases  had,  in  common,  the  low  position  of  the  larynx,  the  thyroid 
cartilage  being  submerged  almost  to  the  thyroid  notch.  The  thyrohyoid 
membrane  was  of  about  thrice  the  normal  vertical  extent,  the  necks  m 
the  two  women,  cases  A  and  C,  being  of  usual  length,  the  hyoid  bone  be- 


B  C 

Fif;.  404. — Scluinatic  illustration  o[  three  cases  of  laryngoptosis  with  deviation 
of  the  trachea.  A  and  C  were  probably  congenital  anomalies.  B  was  associated 
vvitli  mediastinal  cancer.  In  all  three  cases  the  larynx  was  almost  entirely  below 
the  notch  of  tlie  sternum  (S).  FL,  deviation  forward  to  the  left.  BR,  deviation 
backward  to  the  right.     F,  deviation  forward  ;  IJ,  backward. 


ing  only  slightly  lower  than  usual.  The  man's  neck  seemed  (piite  short, 
the  increased  vertical  extent  of  the  thyrohyoid  membrane  apparently  fill- 
ing up  all  the  space  made  by  the  ptosis  of  the  larynx.  In  all,  the  trachea 
was  deviated,  and  in  all  the  esophagus  seemed  to  follow  the  trachea  in 
the  deviation ;  but  it  is  necessary  to  eliminate  case  B  from  consideration, 
because  of  the  mediastinal  malignancy  which  coinpressed  the  trachea 
and  involved  the  esophagus.  In  case  A,  the  deviation  was  first  forward 
to  the  left  and  then  backward  to  the  right.  In  case  C,  the  deviation 
seemed  to  be  directly  backward  immediately  below  the  cricoid.  The 
carinal  respiratory  movements  were  normal  in  cases  A  and  C.  It  is  im- 
possible for  the  author  to  express  an  ofinion  as  to  whether  these  devia- 


-170  nRONXIIOSCOPY  I\   DISEASK.S  Of  TRACHEA  AND  BRONCHI. 

tions  were  congenital  anomalies  or  not,  though  the  fact  of  the  cervical 
ribs  occurring  in  one  case  would  rather  speak  for  a  congenital  condition. 
It  will  require  a  large  series  of  cases  to  arrive  at  detinite  conclusions. 
The  author  had  the  honor  of  exhibiting  case  A  to  Prof.  Killian  upon  his 
visit  to  the  author's  clinic  in  1907. 

Deviation  of  the  trachea  from  diseased  conditions  of  surrounding 
structures  is  quite  common.  In  nearly  every  case  of  verv  large  goitre, 
there  is  more  or  less  deviation  as  well  as  compression.  In  substernal 
goitre,  the  deviation  is.  in  some  instances,  even  more  marked.  Malignant 
growths  and  glandular  masses  in  the  mediastinum  are  perhaps  the  most 
common  causes  of  deviation  of  the  intrathoracic  trachea,  with  aneurysm 
standing  next  in  frequency,  in  the  author's  experience.  The  differential 
diagnosis  of  these  conditions  cannot  be  made,  as  a  rule,  on  the  endo- 
scopic findings  alone ;  hut  when  taken  in  conjunction  with  the  radio- 
graph, the  physical  examination  of  the  chest  and  the  palpation  of  the 
neck,  the  internist  will  usually  be  able  to  make  the  diagnosis  with  great 
accuracy  and  will  give  due  weight  to  the  endoscopic  findings  of  the 
bronchoscopist.  While  not  absolutely  diagnostic,  it  is  well  to  remember 
that  the  infiltrations  of  carcinoma  are  usually  very  hard,  imparting  rigidi- 
ty to  the  deformity  and  compressions  of  the  trachea.  It  should  also  be 
remembered  that  the  level  of  the  arch  points  strongly  to  aneurysm,  that 
the  bifurcation  is  usually  the  seat  of  the  enlarged  masses  of  glands  in 
tuberculous  processes,  and  that  an  esophagoscopy  should  always  be  done 
in  every  case  of  tracheal  deviation  for  the  valuable  light  it  will  often 
throw  on  the  case.  The  author  has  observed  in  a  case  referred  to  him 
by  Dr.  Baetjer  nf  Baltimore,  de\iation  of  the  trachea  in  an  eight-year- 
old  boy  who  had  a  patent  foramen  ovale. 

Compression  stenoses  of  the  traclica  and  Ivonchi.  All  of  the  dis- 
eases mentioned  as  causing  deviation  may  also  cause  compression.  Goitre, 
cervical  or  substernal,  aneurysm  and  malignancy  are  the  most  common, 
and  may  produce  severe  dyspnea.  A  goitre  together  with  a  mass  of 
mediastinal  glands  caused  a  compression  of  the  entire  cervical  and  tho- 
racic trachea  (Fig.  40V)  in  a  leukemic  (leucocytosis  62."),00IM  bov  of 
seven  years  of  age  referred  to  the  author  bv  Dr.  John  W.  I'oyce  for 
tracheotomy.  Not  until  the  long,  cane-shaped  tracheotomic  cannula  en- 
tered the  right  bronchus  was  the  dyspnea  completely  relieved.  The  boy 
died  two  days  later,  but  not  for  want  of  air.  Xo  post  mortem  was  ob- 
tained. Com[)ression  stenosis  of  the  left  bronchus  is  a  not  infrequent 
condition  in  hypertroph}'  of  the  cardiac  auricle.  In  one  such  case  the 
author  found  the  left  bronchus  almost  closed  and  the  esophagus  so  com- 
pressed as  to  interfere  seriouslv  with  swallowing.  There  was  a  i>osticus 
paralysis  of  the  left  side  of  the  larynx.     The  author  has  seen  tracheal 


ERONCnOSCOI-Y  IN   DISEASES  OF  TRACHEA  AND  BRONCHI. 


471 


compression  due  to  mediastinal  emphysema  caused  by  a  fall  down  stairs. 
Compression  stenosis  of  the  trachea  associated  with  pulmonary  emphy- 
sema has  been  studied  in  thirty-two  cases  by  Kahler  (Bib.  21'G),  who 
notes  that  the  stenosis  becoming  much  worse  on  coughing  explains  the 
frightful  dyspnea  from  which  many  emphxsematous  patients  suffer. 

The  author  saw  one  case  of  congenital  tracheal  stenosis  due  to 
goitre.  That  it  was  an  obstructive  case  of  "blue  baby"  was  recognized 
by  Dr.  B.  B.  W'cclisler.     I'rompt  tracheotomy  by  Dr.  S.  Seegman,  and 


Fig.  405. — Compression  stenosis  of  the  entire  cervical  and  thoracic  trachea 
by  a  goitre  and  a  mass  of  glands  in  a  lenkemic  l)oy,  seven  years  of  age.  The  nar- 
row whitish  streak  in  the  lateral  view  is  the  compressed  trachea  and  the  left 
bronchus,  the  latter  being  displaced  backward.  The  uncompressed  right  bronchus 
is  seen.  Tracheotomy  with  a  long  cane-shaped  cannula  relieved  the  dyspnea. 
(Author's  case.     Radiograph  by  Dr.  George  W.  Grier.) 


the  u.se  of  one  of  the  author's  long  tracheal  cannulae  saved  the  patient's 
life. 

The  recognition  of  a  compressive  tracheal  stenosis  with  its  elliptical 
or  scabbard  shape  is  quite  easy.  Of  course,  it  must  be  recognized  that 
during  cough  there  may  be  compression  of  lumen  that  would  be  misin- 
ter()reted  if  not  compared  with  the  lumen  during  inspiration  or  at  the 
momentary  rest  period  between  expiration  and  inspiration.  A  concen- 
tric funnel-like  compression  stenosis  is  exceedingly  rare  and  occurs 
onlv    with    annular  growths   coniplctelv   siu-rmnuling   the   air   tulic.      To 


472  BROXCHOSCOPY  IX   DISEASES  OF  TRACHEA  AND  BROXCHI. 

make  certain  that  such  a  condition  is  really  a  pathologic  and  not  a  normal 
narrowing,  it  is  only  necessary  to  remember  that  there  is  no  narrowing 
normally  in  the  bronchi  between  branches.  The  walls  of  a  suspected 
narrowing  should  be  searched  for  lateral  branches  and  if  none  is  given 
oft  and  yet  narrowing  exists,  we  may  conclude  that  it  is  pathologic,  but 
we  must  be  on  our  guard  not  to  mistake  a  perspective  foreshortening 
for  a  narrowing.  In  a  marked  compression  stenosis  of  the  trachea  the 
walls  will  entirely  collapse  during  coughing.  Normally  the  walls  of  the 
larger  bronchi  and  especially  of  the  trachea  do  not  collapse  though  they 
may  narrow  slightly.  In  children  they  narrow  very  markedly,  especially 
the  membranous  posterior  wall  of  the  trachea,  which  advances  so  far  as 
to  take  up  a  considerable  part  of  the  tracheal  lumen.  The  bronchi  in 
children  narrow  very  markedly  during  cough,  the  narrowing  in  some 
situations  being  concentric,  in  others  scabbard  like. 

To  measure  the  depth  of  a  compression  stenosis  the  beginning  is 
noted  when  the  tube  mouth  has  reached  the  first  observable  narrowing. 
Then  the  tube  is  inserted  until  it  has  passed  entirely  through  the  stenosed 
area  and  arrives  at  a  lumen  of  normal  size  and  contour,  then  the  depth 
is  again  noted.  By  using  very  small  tubes  in  tight  stenosis  it  is  easy 
in  any  case  to  measure  depth  in  this  way,  though,  of  course,  if  preferred, 
olivarv  bougies  such  as  used  for  esophagoscopic  dilatation  may  be  used 
with  the  sense  of  touch  as  a  guide  as  to  the  engaging  of  the  olive  and  its 
emergence  on  the  other  side.  By  either  method  the  measurement  should 
be  repeated  on  withdrawal.  Comparison  of  the  two  measurements  will 
minimize  error. 

Treatment  of  compression  stenoses  of  the  trachea  consists  in  tra- 
cheotomy. Literature  is  full  of  cases  unrelieved  by  tracheotomy  simply 
because  the  ordinary  tracheotomic  cannula  of  the  shops  will  not  reach  l^e- 
low  an  extensive  compression.  It  requires,  in  most  cases,  the  author's 
long  cane-shaped  cannula  as  described  under  ■"Tracheotomy"  (See  also 
Fig.  407).  The  treatment  of  compression  stenosis  of  the  bronchi  con- 
sists in  the  use  of  the  long  cane-shaped  cannula,  if  the  stenosis  is  near 
the  main  bronchial  orifice.  If  deeper  the  intubation  tubes  used  for 
cicatricial  stenosis  of  the  bronchi  may  be  used  (Bib.  "269,  p.  79).  Their 
use  is  indicated  only  when  the  stenosis  is  so  great  as  to  interfere  with 
escape  of  secretions  from  the  subjacent  air  passages. 

Permanent  cure  will,  of  course,  depend  upon  the  curability  of  the 
compressive  mass. 

Thymic  compression  stenosis.  The  author  has  demonstrated  bron- 
choscopically  (Bib.  255  and  2G9)  that  the  enlarged  thymus  can  and  does 
in  some  instances  compress  the  trachea  even  to  the  point  of  asphyxia. 
Four  cases  of  thvmic  tracheostenosis  have  convinced  the  author  of  the 


BKOXCHOSCOPY  IN"   DISKASKS  OF  TRACHKA  AM)  liKONCIII. 


473 


purely  mcch.-mical  CDiulitioiis  ])rescnt  in  cases  of  tliymic  liypertroi)hy ; 
and  having  seen  so  many  illustrations  of  extreme  danger  of  anesthesia 
m  even  the  slightest  stenosis  of  the  trachea,  he  feels  convinced  that  the 
thymus  deaths  attributed  to  "status  lymphaticus"  and  "hyperthymiza- 
tion  of  the  blood"  are  really  nothing  more  or  less  than  arrested  respira- 
tion, which  is,  as  usual,  fatal  because  respiration  when  arrested  by  ob- 
struction cannot  be  started  again  without  either  tracheotomy  or  bron- 
choscopic  oxygen  insufflation.  The  author  would  strongly  urge  that 
when  respiration  ceases  during  anesthesia  and  cannot  be  immediately 
started,  tracheotomy  should  be  done,  a  long  cane-shaped  cannula  in- 
serted, and  amyl  nitrite  insufflated  into  the  trachea.  I'.ctter  still  would 
be  the  insufflation  of  oxygen  through  the  bronchoscope,  or  through  the 
intratracheal  insufflation  catheter.  These  are  not  always  promptly  avail- 
able. Inn  tracheotomy  can  always  be  done  in  a  few  seconds.  A  slight 
degree  of  dyspnea  may  never  be  noticed,  and  mav  quite  readily  be  at- 


FiG.  40!i. — From  a  photograph  of  a  specimen  frmn  a  ncw-licirn  infant  as- 
phy.xiated  by  compression  of  the  trachea  at  A  by  the  large  fourtli  lobe,  T,  of  tlic 
thymus  gland.    (Case  of  Dr.  V.  L.  .Andrews.) 


tributed  to  enlarged  tonsils  or  adenoids.  The  excitement  of  starting  the 
anesthetic  can  very  readily  engorge  a  vascular  structure,  like  the  thymus 
gland  and  the  increased  bulk  compressing  the  trachea  produces  apnea 
just  as  soon  as  the  patient  begins  to  go  under  the  anesthetic.  Artificial 
respiration,  as  ordinarily  done,  is  absolutely  useless  in  the  presence  of 
c\en  very  slight  degrees  of  tracheal  stenosis.  Air  can  be  forced  out  of 
the  lungs,  but  it  cannot  be  drawn  in.  It  is  a  well  known  fact  that  en- 
gorgement of  tissue  like  the  thymus  gland  increases  its  bulk.  If  the 
hypertriijihic  gland  can  compress  the  trachea,  the  engorged  liypertro[]hic 
gland  can  cfimjiress  the  trachea  still  more.  After  death,  the  congestive 
part  of  the  bulk  may  diminish  so  as  not  to  be  noticeable.  .\  beautiful 
auloi)tical  confirmation  of  the  above  mentionetl,  jireviouslv  published 
observations  of  the  author  on  the  purely  mechanical  nature  of  thynnis 
death  is  aft'orded  by  Dr.  \'.  I-.  Andrews'  case.  A  new  born  child  died 
after    making    a    number   of    virilent    ineffective    inspiratory    mu\cments. 


474 


BRONCHOSCOPY  IX   DISEASES  OF  TRACHEA  AND  BRONCHI. 


Autopsy  revealed  a  very  large  four-lobed  thymus.  The  fourth  and  com- 
pressive lobe.  T.  was  compressing  the  trachea  at  the  end  of  the  dotted 
line,  A,  Fig.  -iOG.     Dr.  Andrews'  report  is  as  follows : 

"The  thymus  is  short  and  thick  and  contains  four  lobes.  It  meas- 
ures 4  cm.  in  length,  3..")  cm.  in  width.  l.T-")  cm.  in  average  thickness. 
There  is  a  right,  left  and  middle  lobe.    The  left  lobe  is  small.    The  fourth 


Fig.  407. — Thymic  traclieostenosis  temporarily  reliesed  with  the  author's 
long  cane-shaped  tracheal  cannula.  The  shadow  of  the  hypertrophied  thymus 
shows  to  the  right  of  tlie  cannula,  and  especially  strongly  at  the  right  of  the  lower 
end.     (Authors'  case.) 


lobe  extends  from  beneath  the  lower  ends  of  the  right  and  midille  lobes 
upward  and  outward,  at  an  angle  of  45".  into  the  right  pleural  cavity  for 
a  distance  of  1.5  cm.  The  upper  end  is  free  in  the  pleural  cavity  and  is 
covered  by  a  thin  movable  membrane  (pleura?).  The  lower  end  of  this 
lobe  lies  over  the  trachea  beneath  the  lower  part  of  the  middle  and  right 
lobes  and  at  this  point,  1  cm.  above  the  bifurcation  of  trachea,  the  thymus 
measures  2  cm.  in  thickness.     Here  the  trachea  presents  a  flattened  ap- 


HRONCHOSCOPY  IN   DISKASKS  01*  Tlt.\CHI-A   AND  RRONCIII. 


475 


pearance  antero-postcriorly.  more  marked  on  the  right  side  than  on  the 
left." 

In  tln-ee  of  the  anthor's  cases  the  compression  was  from  before  back- 
ward. In  the  last  case  it  was  lateral  ihe  axis  of  the  scabbartl-like  lumen 
being  from  the  left  posteriorly  to  the  right  anteriorly. 

As  shown  by  FetterhotT  and  Gettings  (quoted  by  H.  C.  Clark)  com- 
pression of  the  trachea  may  occur  from  a  left  innominate  vein  engorged 
by  an  embarrassed  right  heart,  the  dilated  vein  being  forced  to  extend 
I)OStcriorly  because  braced  anteriorly  by  the  thymus.     Treatment  of  thy- 


Fk;.   408.— riiol(ij;r;ipli 
mopexy.     ( .Author's  case.) 


)f   a   child   of   two   vears  taken   si.x   months   after   thy- 


mic compression  stenosis  is  the  same  as  mentioned  for  other  tracheal 
compressions,  namely  the  cane-shaped  cannula  of  sulhcient  length  to 
reach  below  the  compression  (Fig.  in?).  As  the  author  has 
pnnen,  hypertrophic  thymus  is  dangerous  solely  from  a  mechanical  com- 
I)ressive  pomt  of  view.  I  le  who  will  see  that  a  good  respiratory  channel 
is  mechanically  maintained  need  not  worry  about  such  purely  hypothet- 
ical conditions  as  "hyperthymization  of  the  blood,"  etc.  Having  tempor- 
arily i-arcd  for  the  compression  stenosis  by  tiie  insertion  of  the  long  can- 
nula, the  next  step  is  either  thymopexy  nv  thymectomy  (subtotal).  In 
the  author's  first  cases  all  of  tlie  gland  that  could  be  brought  up  was 
shelled  oiU  of  its  capsule  anil  remo\ed.      In  the  last  case  an  (.•<|u.'dly  sat- 


476  BKOXCHOSCOPY  IN  DISEASES  OF  TRACHEA  AXD  BROXCIII. 

isfactory  result  was  obtained  by  thymopexy.  This  last  case  was  as  fol- 
lows : 

Robert  C,  aged  two  years,  was  referred  to  the  author  by  Dr.  W.  H. 
Wesley  for  dyspnea  and  noisy  breathing  of  three  montlis'  duration.  All 
of  the  accessory  respiratory  muscles  were  working  vigorously.  The 
suprasternal  and  clavicular  fossae  were  indrawing  and  there  was  a  typi- 
cal '"trichter  brust"  at  each  inspiration.  Bronchoscopy  rexealed  a  tracheal 
compression  reducing  the  lumen  to  a  narrow  chink  whose  curved  axis 
was  from  the  left  posteriorly  to  the  right  anteriorly.  Tracheotomy  was 
done  under  infiltration  anesthesia  and  the  enormous  thymus  bulged  large- 
ly into  the  wound.  It  was  drawn  upward  and  stitched  with  linen  to  the 
tendons  of  sternomastoid  muscles  and  to  the  skin  and  tissues  at  the  top 
of  the  sternum.  The  tracheal  cannula  was  removed  on  the  eighth  day  and 
the  child  was  discharged  well  on  the  fifteenth  day.  There  had  been  no 
return  of  the  dyspnea  when  the  photograph,  Fig.  408,  was  taken  six 
months  later. 

Remarks.  The  lateral  compression  visible  endoscopicallv  has  not 
previously  been  observed.  From  this  one  case  it  is  not  wise  to  conclude 
that  thymopexy  is  to  be  preferred  in  all  cases  to  subcapsular  subtotal 
thymectomy.  Doubtless  part  of  every  very  large  gland  should  be  re- 
moved. Total  removal  is  probably  impossible  even  if  desirable.  An 
able  article  with  a  report  of  fifty  operated  cases  is  written  by  Parker 
(Bib.  428).    See  also  a  valuable  contribution  by  Schwinn,  Bib.  490. 

Inflammations  and  their  sequelae.  Chronic  circumscribed  tracheo- 
bronchitis is  a  common  affection  in  adults.  Acute  circumscribed  tracheo- 
bronchitis is  rather  frequent  in  the  course  of  influenza,  (q.  v.)  as  mani- 
fested by  the  dry,  barking  cough  and  severe  burning  pain  back  of  the 
sternum.  In  children  an  occasional  interesting  complication  is  seen  in 
the  form  of  laryngeal  spasm,  doubtless  a  reflex  from  an  irritated  tracheal 
mucosa,  dift'ering  from  the  ordinary  diffuse  bronchitis  in  that  the  im- 
portant lesion  is  limited  to,  or  at  least  most  marked  in,  the  trachea  and 
larger  bronchi.  In  some  instances  it  is  limited  to  a  portion  only  of  the 
mucosal  area  of  these  passages.  A  case  of  chronic  purulent  bronchitis 
is  described  in  the  subsequent  paragraph  on  tuberculosis.  Non-tuber- 
culous abscess  of  the  lung  has  been  found  and  evacuated  bronchoscopic- 
ally  (Bib.  271)  by  the  author.  The  bronchoscope  in  relation  to  another 
case  of  pulmonary  abscess  is  shown  in  Fig.  13fi.*  Freudenthal  records 
non-specific  ulceration  of  the  bronchial  mucosa  in  one  case.  Ephraim 
reports  nineteen  relative  cures  of  chronic  bronchitis  out  of  23  cases.  In 
many  in.stances,  a  single  application  only,  was  necessary.  The  applica- 
tions were   followed  by  increased  expectoration  and  a  total  change  of 

•As    stated   by   George    L.    Richards,    a    non-tuberculous    pulmonary    ab."5cess 
justifies  the  suspicion  of  foreign-body  origin. 


BRONCHOSCOPY  IN  DISKASES  OF  TRACHEA  AND  ISKOXCIII.  477 

secretions.  The  solutions  used  were  novocain  and  suprarenin  dissolved 
in  salt  solution  in  some  instances,  and  in  others  in  a  five  per  cent  solution 
of  potassium  or  ammonium  iodid.  The  ammonium  iodid  was  used  espe- 
cially in  the  dry  form  of  bronchitis,  and  a  few  drops  of  iodine  were  added 
to  it.  In  a  number  of  cases  he  also  used  weak  solutions  of  argentic 
nitrate.  In  two  cases  of  chronic  purulent  bronchitis,  permanent  healing 
was  accomplished  by  repeated  insufflation  of  turpentine  emulsion  to 
which  suprarenin  had  been  added.  In  one  case  each  of  chronic  pneu- 
monia and  of  double  gangrene  of  the  lung,  the  procedure  was  ineffective. 
Bronchiarctla  and  bronchiectasis.  Bronchial  stenoses  comprise  a 
number  of  different  lesions.  The  chief  causes  of  cicatricial  bronchial 
stenosis  are  traumatism,  syphilis  and  tuberculosis ;  or,  perhaps,  more  ac- 
curately, the  secondary  infections  complicating  these  lesions.  Tuber- 
culous processes  are  of  such  slow  progress,  as  a  rule,  that  the  lung  ac- 
commodates itself  to  the  altered  conditions,  and  cicatricial  bronchial 
stenoses  secondary  to  tuberculosis  rarely  require  local  treatment,  though 
they  do  occur  as  the  result  of  erosion  through  the  bronchial  wall.  The 
author  has  seen  si.x  such  cases.  Cicatricial  stenoses,  in  some  instances, 
may  require  dilatation  in  order  to  secure  proper  drainage  of  the  infra- 
strictural  bronchiectatic  cavity,  and  thus  cure  the  patient  of  bronchiectasis 
with  its  distressing  cough,  foul  expectoration,  dyspnea  and  lesser  symp- 
toms. For  syphilitic  strictures  it  may  be  necessary  to  use  prolonged  in- 
tubation with  bronchial  intubation  tubes,  put  in  place  with  the  aid  of  the 
bronchoscope  and  left  in  situ  for  a  period  of  from  one  to  seven  days. 
The  tube  should  be  left  for  a  few  hours  in  case  of  daily  removals,  or 
a  few  days  in  case  of  weekly  removals.  Extubation  is  performed  with 
an  extubator  used  through  the  bronchoscope.  In  order  to  obtain  a  suffi- 
cient lumen  for  the  insertion  of  the  intubation  lube,  a  laminaria  or  tupelo 
tent  may  be  used,  placed  in  situ  with  the  author's  instrument  for  the  pur- 
pose (Rib.  2(!!)).  The  tent  is  open  to  the  objection,  that  it  obstructs  all 
drainage  for  the  time  it  is  in  place,  though  this  need  be  for  only  a  few 
hours.  Divulsion,  as  hereinafter  described,  is  the  best  method  by  which 
to  obtain  a  suflicient  iunien  for  intubation,  and  even  if  some  trauma  re- 
sults from  divulsion,  cicatricial  tissue  is  not  readily  infected  by  the  or- 
ganisms present  to  which  the  patient  is  already  more  or  less  immune. 
Endobrtincbial  neoplasms  mav  cause  bronchiectasia.  This  is  an  addi- 
tional reason  for  bronclioscojiing  every  case  with  bronchiectatic  symptoms. 
P.ronchiectasis  and  bronchiarctia  resulting  from  foreign  bodies  are  con- 
sidered in  Chapter  X\'l.  Cicatricial  stenoses  of  the  lironchi  are  \ery 
readily  rccognizt'd  by  tb.e  cicatricial  nature  of  their  walls  with  a  total 
absence  of  rings.  This  condition,  of  cr)urse,  may  be  more  or  less  con- 
fused l)v  inlbmnnatory  states  wl;icli  urdinarily  mask  the  view  of  rings. 


478  BRONCHOSCOPY  IN  DISEASES  OE  TRACHEA  A\D  BRONCHI. 

Any  one  familiar  with  the  neat,  clear,  sharp  edges  and  more  or  less 
oval  lumen  of  the  openings  into  bronchial  branches  would  never  mistake 
these  when  covered  with  normal  mucosa  for  the  lumina  of  stenotic 
bronchi.  Until  the  sense  of  gauging  depth  with  one  eye,  only,  has  been 
acquired  by  practice  perspective  foreshortening  of  the  image  may  be  mis- 
taken for  a  gradual  narrowing  of  the  lumen.  Emma  E.  Musson  (  Bib.  401) 
reports  excellent  results  in  the  endnscopic  treatment  of  bronchiectasis, 
by  injection  as  above  mentioned,  of  a  dram  of  freshly  prepared  2o  per 
cent  argATol  solution.  Gereda  advises  hydrogen  peroxid  injections.  Eph- 
raim's  medication  is  mentioned  at  the  beginning  of  the  chapter. 

Bronchial  asthma.  The  literature  of  bronchial  asthma  is  a  wilder- 
ness of  theory.  The  reason  for  this  is  that  our  knowledge  at  present 
rests  upon  no  foundation  of  morbid  anatomy,  because  the  autoptical  find- 
ings are  inconclusive,  but  we  have  evidence  that  there  is  a  living  morbid 
anatomy  to  be  studied  bronchoscopically,  and  the  author  would  urge  all 
bronchoscopists  carefully  to  study,  during  the  attacks,  every  case  of 
asthma  available.  If  this  be  done,  bronchoscopic  accomplishment  here 
promises  to  be  second  only  to  that  in  the  field  of  foreign  body  extractions. 
The  author  advises  the  ignoring  of  the  assumption  of  "irritation  of  the 
respiratory  center,"  "asthmogenous  points,"  "spasm  of  the  muscles  in 
the  bronchial  walls,"  "swelling  of  the  bronchial  mucosa,"  and  all  the 
other  previously  accepted  statements  as  to  the  conditions.  It  is  absolutely 
necessary  to  start  in  with  the  mind  blank  to  previous  theories  and  simply 
observe  and  record  the  bronchoscopic  pictures  in  about  1,000  cases.  In 
order  to  get  an  accurate  picture,  it  is  necessary  that  this  be  done  without 
anv  anesthesia,  general  or  local,  in  at  least  one  of  the  sittings  with  each 
patient,  in  order  that  the  bronchoscojiic  picture  shall  not  be  altered  by  the 
application  of  the  local  anesthetic;  for  it  is  well  known  that  applications 
of  cocaine  to  anv  part  of  the  air  passages,  even  abo\e  the  larynx,  will 
modify  an  asthmatic  attack,  and,  therefore,  in  all  probability,  would  alter 
bronchoscopic  appearances.  On  the  other  hand,  irritation  of  the  bron- 
choscope acting  as  a  foreign  body,  excites  reflexes  which  may  also  alter 
the  endoscopic  picture.  For  these  reasons,  controlled  observations  with 
and  without  anesthesia  are  necessarj-,  and  they  should  be  separately  re- 
corded, making  a  number  of  observations  each  way.  In  this  manner,  we 
may  record  a  living  morbid  anatomy  for  asthma.  The  bronchoscopic 
picture  in  asthma  during  the  attack  is  variously  reported  by  different 
observers  in  different  cases.  Xowatny  observed  redness  and  swelling 
of  the  bronchial  mucosa.  Galebsky  reports  redness  and  edema  limited 
to  one  area.  Horn  reports  a  spasmodic  stenosis  simulating  a  cicatricial 
stenosis,  which  was  foimd,  at  a  later  bronchoscopy,  to  have  disappeared. 
The  author  has  been  able  to  observe  onlv  two  cases  during  the  attack. 


BRONCIIOSCorY  IN   DISKASKS  01"  TK.\CIII:a  AND  BROXCIII.  47!J 

In  iieitlier  of  these  was  lie  able  to  make  out  spasmodic  stenosis,  and  the 
color  of  the  mucosa  was  more  purple  than  red.  The  bronchi  were  all 
filled  witii  secretions  and  the  patient's  distress  was  completely  relieved 
by  the  bronchoscopy  with  removal  ot  secretions  without  any  application 
of  any  kind,  tlie  bronchoscopy  being  done  without  any  anesthesia,  gen- 
eral or  local.  The  findings  and  the  results  were  the  same  in  both  in- 
stances. Both  [latients  had  a  recurrence  of  their  attacks  at  about  the 
Usual  intervals,  no  medication  havin;.:  been  used.  All  the  foregoing  ob- 
servations by  the  ditferent  observers  were  during  the  attacks,  and  they 
all  go  to  show  that  there  is  a  very  varied  bronchoscopic  picture.  Be- 
tween the  attacks,  the  pictures  observed  bv  most  of  the  observers  have 
been  normal,  except  in  some  cases  where  unusual  dilatation  of  the  vessels 
has  been  observed.  I'Veudenthal  records  the  appearance  of  a  scar-like 
mass  obstructing  the  entire  lumen  of  the  bronchus.  The  obstruction  was 
overcome  by  the  local  application  of  a  20  per  cent  solution  of  cocaine, 
liberating  an  enormous  discharge  of  secretions.  In  another  case  adrenalin 
was  used  with  excellent  results  after  the  air  passages  were  cleared  of 
secretion.  One  of  his  patients  was  practically  cured,  remaining  perfectly 
well  and  free  from  attack  at  the  end  of  six  months.  In  this  case,  an 
emulsion  of  orthoform  a?  follows  was  used: 

Orthoform   (>.5 

:\Ienthol    0.5 

Formalin     0.5 

Ol.  amygdal.   dul.  15.n 

Gum   acac.  10.0 

Ac|ae  ad fiO.O 

M.  F.  Enuilsif). 
.\bout  locc.  was  injected  twice  weekly  for  ten  applications.  Then 
during  an  intermission  of  the  treatments,  after  the  great  excitement  of 
being  exhibited  at  a  medical  meeting,  a  severe  recurrence  took  ])lace. 
After  ten  more  treatments  the  attacks  ceased  and  the  patient  was  still 
well  at  the  end  of  six  months.  The  jiatient,  a  young  man  of  27,  had  had 
asthma  since  cliildJKKjd  and  ;ill  i>\  tin  members  of  his  mnther's  family 
were  asthmatic.  He  had  never  been  able  to  slecj)  an  entire  night  rest- 
fully.  In  another  case,  Frendenthal  used  propacsin  instead  of  orthoform 
in  a  like  am(}unt.  The  applications  were  made  in  the  morning  \\  ith  stoni.icii 
empty.  (  )ut  of  a  total  of  1.3  patients,  b'reudenthal  considered  S  cured, 
3  improved  and  2  not  benefited.  Ephraim  reports  1  •'>■'!  cases  of 
asthma  treated  endolironchially  with  a  spray  of  su|irareuin  with  novo- 
cain with  excellent  results.  .\  long-tubed  bronchosco])ic  atomizer  was 
used.  In  most  cases  free  expectoration  resulted  within  the  following 
twelve  hours.    The  results  were  not  so  good  in  the  spasmodic  dry  asthma. 


480  BRONCHOSCOPY  IN  DISEASES  OF  TRACHEA  AND  BRONCHI. 

nor  in  cases  in  which  neurasthenia  predominated.  Results  also  were  not 
fa\orable  in  cases  in  which  immediate  rehef  of  the  attack  did  not  follow 
the  application  of  the  solutions  injected  during  the  attack.  Of  the  88 
cases  in  which  ultimate  results  were  known,  73  were  recorded  as  good. 
Of  these,  48  were  free  from  recurrence,  some  of  them  as  long  as  1^4 
years.  Most  of  these  were  of  the  most  severe  type  in  which  scarcely  a 
night  in  years  had  passed  without  an  attack.  In  seven  other  cases  the 
attacks  were  notably  milder  and  at  longer  interv'als,  the  permanent  dis- 
tress less,  without,  however,  permanent  cure.  Ephraim  thought  these 
effects  were  due  to  medicinal  action  of  the  substance  injected,  and  not 
to  any  mechanical  effect,  because  he  had  observed  that  the  injection  of 
normal  salt  solution  alone  produced  no  objective  changes,  and  a  patient 
showing  diffuse  bronchial  rales  before  insufflation,  showed,  after  in- 
sufflation, a  vanishing  of  the  rales  on  the  side  which  had  been  treated. 
In  none  of  the  133  cases  had  there  been  any  untoward  effect.  As  pointed 
out  by  Dr.  James  Adam  in  one  of  the  best  practical  works  on  asthma 
that  has  ever  appeared  (Bib.  3),  asthma  in  most  cases  is  essentially  a 
toxemia  and  no  treatment  can  be  successful  without  recognition  of  this 
element  in  the  etiology. 

influenzal  tracheitis.  Of  all  forms  of  tracheitis,  perhaps  the  least 
frequently  dilTerentiated  as  a  morbid  entity  is  influenzal  tracheitis.  When 
the  author  observed  his  first  cases  in  the  prebronchoscopic  days  (1889) 
he  believed  that  he  had  discovered  a  new  disease.  Indirect  methods 
yielded  few  and  uncertain  pictures  of  the  tracheal  lesions,  and,  indeed, 
none  in  the  most  interesting  class  of  cases,  namely  those  occurring  in  in- 
fants and  children.  The  advent  of  direct  methods  of  examination  per- 
mitted of  accurate  observation  of  the  clinical  appearances  of  the  tracheo- 
bronchial mucosa.  A  very  good  illustration  made  from  the  author's 
color  drawing  of  one  of  these  cases  has  been  published  (Bib.  243).  The 
clinical  appearances  might  be  classified  vmder  a  number  of  dift"erent 
types,  but  it  has  seemed  to  the  author  that  the  differences  he  has  ob- 
served are  reallv  different  stages  of  the  same  disease.  The  first  stage 
has  much  the  same  appearance  as  in  influenzal  inflammation  of  the  nasal 
mucosa  at  the  same  stage.  The  tracheal  mucosa  is  reddened.  Its  color 
deepens.  Swelling  of  the  mucosa  begins.  Later,  an  exudate  forms,  at  first 
serous,  then  mucoid,  then  purulent  and  finally  thick,  tenacious  and  exceed- 
ingly difficult  of  expectoration  even  by  the  robust  adult.  In  infants  who 
naturally  are  almost  incapable  of  expectoration,  death  may  occur  from 
inability  to  rid  the  air  passages  of  secretion  and  drowning  of  the  patient 
in  his  own  secretions  (q.  v.)  may  be  threatened.  The  bronchi  or  even  the 
trachea  itself  may  be  occluded  by  mucosal  swelling,  or  edema,  actually 
causing   death   by   the   stenosis.     Both  these  conditions  are  inde|ien(lent  of 


BRONCHOSCOPY  IN   DISK.\?i;S  OF  TRACHKA  AND  KRONCIII.  481 

hroncho-pneumDnia.  which  may  nr  may  not  exist.  Tlie  author  has  observed 
blood-clots  on  the  surface  of  the  inflamed  membrane,  without  true  hemor- 
rhage, similar  to  those  in  nasal  influenza,  first  described  by  D.  Braden  Kyle. 
Superficial  erosions  of  the  tracheal  mucosa  have  been  seen  by  the  author 
in  a  number  of  cases.  There  was  in  no  case  any  true  adherent  mem- 
branous exudate,  on  which  alone  the  difl:'erential  diagnosis  rests.  Clini- 
cally a  severe  case  of  influenzal  laryngo-tracheitis  cannot  be  differentiated 
from  diphtheria,  as  it  presents  the  same  clinical  picture,  even  to  the 
adynamia.  Direct  inspection  showing  abscess  of  a  fibrous  exudate  will 
I)romptly  decide,  and  corroboration  by  the  laboratory  from  the  specimens 
bronchoscopically  removed  will  follow.  A  bronchoscope  need  not  be 
inserted  below  the  larynx.  The  glottis  may  be  propped  open  with  the 
tube  mouth  (supraglottic  tracheoscopy  q.  v.)  or  often  the  trachea  can  be 
clearly  seen  by  use  of  the  laryngoscope  alone.  In  some  instances,  there 
seemed  to  be  but  little  laryngeal  inflammation,  the  croupy  cough  being 
probably  due  chiefly  to  spasmodic  conditions  excited  by  the  inflammation 
below.  The  laboratory  is  seldom  of  aid  if  only  secretions  from  the 
l)har\nv  are  sent.  If  the  secretion  is  obtained  by  direct  methods  from 
the  trachea,  a  reliable  report  nearly  always  can  be  had  from  specimens 
taken  through  the  sterile  bronchoscope  which  prevents  contamination 
with  organisms.    A  typical  case  mav  be  cited: 

The  author  was  called  to  see  an  infant,  aged  seven  months,  suftering 
\\  ilh  extreme  ins])iratory  dysjjuea,  with  croupy  cry  and  stridulous  breath- 
ing, but  no  cougii.  The  onset  had  lieen  gradual,  not  nocturnal  or  sudden, 
two  weeks  before,  .\ntitoxin  had  been  given  without  relief.  Pneumonia 
had  been  excluded  l)y  Dr.  Royce  and  laryngismus  stridulus  b\'  an  able 
laryngologist.  who.  however,  jjointed  out  to  us  evidences  of  a  certain 
element  of  spasm  in  the  case.  Temperature,  103":  pulse,  1110  :  respira- 
tion, 32.  The  first  glance  at  the  larynx  through  the  direct  lar)-ngoscoi)e 
showed  it  to  ije  free  from  edema  or  other  obstruction  or  even  active  in- 
flammation. When  the  bronchoscope  was  introduced,  there  was  absolutely 
no  cough,  (no  anesthetic  used)  and  during  the  entire  examination,  last- 
ing about  five  minutes,  there  was  not  one  single  effort  to  cough.  The 
tracheal  mucosa  was  intenselv  inflammed.  and  there  was  a  tenacious 
secretion  adherent  in  scattered  locations.  This  secretion  was  wiped  away 
readily,  leaving  no  erosion  nor  bleeding.  The  bronchial  mucosa  was  in- 
tensely inflammed  in  all  the  larger  tubes :  the  smaller  tubes  were  ob- 
structed with  pus  which  was  moved  to  and  fro  in  the  respiratory  current, 
but  there  was  no  coughing  efi'ort  to  expel  it.  Smears  made  from  the 
sterile  swabs  passed  through  the  sterile  bronchoscope,  showed  an  abun- 
dance of  influenzal  organisms  (Dr.  Ernest  W'illets).  There  was  a  little 
streak  of  pus  extending  upward  betw'een   the  arytenoids,  and  out  over 


482  BRONCHOSCOPY  IN  DISEASF.S  OF  TRACHEA  AND  BRONCHI. 

the  upper  edge  of  the  party  wail.  No  anesthetic,  general  or  iocal.  was 
used  and  the  child  seemed  in  no  way  inconvenienced  by  the  bronclio- 
scopy.  Tlie  child  made  a  slow  hut  complete  recovery.  The  interesting 
points  about  this  case  are  the  inspiratory  dyspnea  without  laryngeal  ob- 
struction ;  the  total  absence  of  the  cough  reflex;  the  severe  tracheo-bron- 
chitis  without  pneumonia ;  the  ease  and  certainty  with  which  the  laryn- 
geal diagnostic  question  can  be  decided  by  direct  laryngoscopy.  It  is  in- 
teresting to  consider  what  became  of  the  endobronchial  secretion.  The 
interarytenoid  streak  was  evidence  of  unimpaired  ciliary  activity,  so  that 
it  seems  probable  that  a  portion  of  the  pus  was  expelled  in  this  way,  the 
remainder  being  absorbed.  The  secretions  in  some  instances  require 
aspiration  to  save  life.  Absence  of  the  cough  reflex  in  influenzal  trache- 
itis is  seen  only  in  infants,  and  is  not  present  in  ever}'  infantile  case. 

The  dro7vning  of  the  patient  in  his  own  secretions.  (Bib.  232). 
When  tracheal  and  bronchial  secretions  are  in  excess  of  the  amount  re- 
quired properly  to  moisten  the  inspired  air  they  become  a  menace  to  life 
unless  removed.  Under  almost  all  circumstances  the  normal  activities  of 
the  cough  reflex,  forced  expiration,  and  ciliary  action  remove  these  secre- 
tions. There  are  certain  circumstances,  however,  under  which  these 
normal  agencies  are  inefficient.  \^arious  drugs,  especiallv  anti-bechics, 
hinder  the  action  of  the  normal  agencies ;  hence  should  always  be  avoid- 
ed. The  writer  has  always  opposed  their  use  in  all  laryngeal  and  tracheal 
surgery  and  in  bronchoscopy.  Doubtless  many  of  the  post-anesthetic 
pneumonias  in  surgery  remote  from  the  air  passages,  have  been  due  to 
the  abolition  of  agencies  by  which  secretions  are  normally  removed  from 
the  air  passages.  Perhaps  the  most  frequent  etiologic  factor  in  the  fail- 
ure to  rid  the  air  passages  of  secretion  is  age.  An  infant  cannot  ex- 
pectorate and  is  surprisingly  inefficient  in  getting  secretions  out  of  air 
passages  even  as  far  out  as  the  laryngo-pharynx.  Adults  as  well  as 
children  when  dying  often  fill  up  with  secretions  which  they  are  too  feeble 
to  expectorate,  and  in  some  instances,  by  the  failure  of  the  respiratory 
blood  changes,  drowning  is  the  final  mechanism  of  mortality  in  death 
primarily  due  to  disease  remote  from  the  air  passages.  The  complex 
physiologic  co-ordinated  mechanism  by  which  secretions  are  normally 
removed  is  too  lengthy  to  be  entered  upon  here ;  but  disturbances  of 
laryngeal  motility  and  in  the  author's  experience,  bilateral  cadaveric 
paralysis  especially,  are  frequently  associated  with  the  condition  which 
the  writer  has  termed  the  "drowning  of  the  patient  in  his  own  secre- 
tion." One  of  these  cases  seen  many  years  ago  at  the  Western  Pennsyl- 
vania Hospital  with  Dr.  Clarence  Ingram  was  an  excellent  illustration. 
A  woman,  aged  forty  years,  was  dying  of  general  lymphosarcomatosis. 
Pressure   from   the  mediastinal  or  cervical  iieoplasmata  produced  a  bi- 


BRONCHOSCOPY  IN   DISKASKS  OK  TRACHKA  AND  BRONCHI.  483 

lateral  cadaveric  paralysis.  The  level  of  the  frothy  tlnid  could  be  seen 
rising  and  falling  first  in  the  main  bronchi,  then  higher  and  higher  in  the 
trachea  until  the  level  of  the  upper  laryngeal  orilice  was  reached.  The 
woman  could  not  expectorate.  Had  she  not  had  other  conditions  and 
lesions,  it  would  have  been  easy  to  have  ])rolonged  life  indefinitely  so 
far  as  drowning  was  concerned  by  the  bronchoscopic  aspiration  of  the 
fluid.  The  author  has  done  this  in  other  cases  with  the  result  of  saving 
the  patients.  Before  the  days  of  bronchoscopy,  he  did  a  few  tracheotom- 
ies for  this  purpose  with  excellent  results;  secretions  could  then  be 
readily  removed  by  a  nurse  trained  in  tracheal  work — secretions  that 
could  never  have  been  expectorated.  In  children,  Dr.  Boyce's  method 
of  assisting  expulsion  of  tracheo-bronchial  secretion  by  holding  the  child 
up  by  the  heels  has  often  proved  efficient  and  has  tided  over  a  dangerous 
period.  Perhaps  the  most  important  class  of  cases  is  that  in  which  the 
secretions  due  to  traumatism  or  irritation  of  a  foreign  body  in  the  lower 
air  passages  gradually  accumulate  and  as])hyxiate  the  patient.  One  of  the 
only  two  tracheotomies  (in  previously  normal  cases  I  done  l>y  the  author 
for  dyspnea  after  the  removal  of  the  foreign  bodies,  would  not  have  been 
needed  had  he  known  what  he  has  since  discovered,  namely,  that  chil- 
dren feeble  from  prolonged  respiratory  efifort,  will  in  some  instances  and 
after  certain  kinds  of  foreign  bodies,  fill  up  with  tracheo-bronchial  se- 
cretions and  will  die  if  not  relieved.  It  would  seem  that  some  of  the 
instances  rei)orle(l  by  various  writers  in  which  children  have  died  in  an 
unex])lained  manner  after  the  removal  of  foreign  bodies  may  be  ac- 
counted for  in  tliis  way.  The  condition  was  first  pointed  out  to  the  au- 
thor a  number  of  vears  ago  by  l^r.  KUen  |.  i'atterson.  I'erhaiis  the  best 
case  to  cite  as  an  illustration  is  the  following: 

John  K.,  aged  six  years,  referred  to  the  author  by  Dr.  Wagner. 
Prior  to  coming  under  the  care  of  Dr.  Wagner,  the  chilcl  had  gone 
through  the  usual  treatinent  by  antitoxin  and  (piarantine  for  a  croupy 
cough  with  temj)erature  elevation,  due  to  a  beech-nut  hull,  which  had 
been  cast  about  in  the  trachea  and  bronchi  for  three  weeks.  A  grayish 
apiicarancc  of  the  skin  due  to  dyspnea  favored  the  diphtheritic  diagnosis. 
The  beecii-nut  hull  and  a  large  quantity  of  secretion  were  removed  at  the 
Presbyterian  Hospital,  by  ijronchosco])y.  'I'liat  night  the  patient  be- 
came extremely  dyspneic  and  cyanotic.  Bronchoscopic  removal  of  a 
large  quantity  of  thick  viscid  secretion  gave  complete  relief.  There  was 
a  less  severe  recurrence  of  the  symptoms  the  next  night  but  the  chil<l 
had  then  rallied  enough  to  rid  itself  of  secretions  which  were  moreover 
less  tenacious.     The  child  made  a  rapid  recovery. 

There  have  been  twelve  of  these  cases  in  tlie  j)raclico  of  Dr.  I'attor- 
son  and  the  autlmr.      In   simie  the  aspiration  of  secretion  was  sul'licienl  ; 


484  BRONCHOSCOPY  IN  DISEASES  01'   TRACHEA  AND  BRONCHI. 

in  two  instances  tlie  administration  of  oxygen  through  the  bronchoscope 
after  the  removal  of  the  secretions  saved  life.  For  this  the  bronchoscope 
with  the  anesthetic  attachment  of  Dr.  T.  Drysdale  Buchanan  was  found 
very  convenient  as  it  permitted  of  the  slightest  interruption  of  the 
flow  of  oxygen  during  the  removal  of  secretions  by  "sponge  pumping."  Tn 
one  instance  the  swelling  of  the  mucosa,  in  other  words  the  serous 
exudate  into  the  mucosal  tissue,  prevented  the  pulmonic  interchange  of 
gases ;  the  oxygen  passed  down  through  the  bronchoscope  could  not  be 
taken  up  and  the  child  died.  This  was  a  case  of  influenzal  tracheo 
bronchitis  complicated  by  pneumonia.  It  was  not  a  foreign  body  case. 
In  one  instance  the  secretions  of  an  influenzal  tracheitis  were  so  gelatin- 
ous as  to  rec|uire  removal  with  forceps.  In  some  of  the  cases  the  se- 
cretions were  so  viscid  the_\-  could  not  have  been  drawn  through  any 
form  of  tubal  aspirator. 

Bronchoscopy  for  the  relief  of  jiatients  threatened  with  drowning 
in  their  own  secretions  is  a  new  and  important  held  of  usefulness  for 
the  bronchoscope  as  an  aid  to  general  medicine  and  surgery. 

Since  the  foregoing  was  written  a  number  of  confirmatory  observa- 
tions have  been  made  by  others,  notably  by  Carpenter  ( IHb.  li!)). 

Gangrene  of  the  lung.  Guisez  reports  a  case  of  pulmonarv  gan- 
grene of  verv  grave  prognosis  cured  by  intrabronchial  injection  of 
guiacol  in  oil  with  occasional  injections  also  of  iodoform  suspended  in 
oil.     Jqjhraim's  results  were  unfavorable. 

Jneiirysm.  It  is  probable  that  bronchoscopy  will  repeat  the  historj' 
of  the  Roentgen  ray — aneurysms  will  seldom  be  overlooked,  but  will 
often  be  diagnosticated  when  absent.  The  ordinary  normal  aortic  im- 
pulse is  most  astonishing.  It  is  only  after  repeated  examinations  that 
one  grows  accustomed  to  it.  Any  thoracic  tumor  compressing  the  bron- 
chus may  show  a  transmitted  pulsation.  In  one  case,  that  of  a  woman 
of  50,  there  was  distinct  stenosis  from  external  pressure,  with  an  im- 
pulse that  seemed  expansile  rather  than  merely  transmitteil.  Study  of 
the  symptoms  practically  negatived  the  suspicion  of  aneurysm.  The  pa- 
tient was  a  neurasthenic  and  had  the  palpable  relaxed  abdominal  aorta 
so  common  to  that  class  (Boyce).  It  seems  highly  probable  that  her 
bronchial  compression  was  due  to  a  similar  condition  in  the  thoracic 
aorta.  An  aneurysmal  sac  may  transmit  little  or  no  jnilsation.  The  fact 
that  a  bronchoscopically  or  esophagoscopically  visible  bulging  ])ulsates  is 
far  from  conclusive  evidence  of  aneurj'sm.  It  is  a  frequent  error  to  as- 
sume that  the  siiape  and  position  of  the  in-bulging  is  indicative  of  the 
location  of  the  ])eritracheal  compressive  mass.  It  must  not  be  assumed 
that  because  the  apparent  bulging  is  from  behind  that  it  cannot  be  an 
aneurysm  of  the  aortic  arch.     Tlie  compression  may  be  applied  in  front 


nROXCIinSCoPY  in    DISEASKS  Ol"    I'RACIIFIA   AM)  I'.RONCHI.  485 

or  at  the  side.  and.  yet.  Iieeause  of  tlie  posterior  deticiencv  of  the  traclieal 
cartilage,  the  endoscopic  ajijiearance  may  be  that  of  compression  from 
behind.  Often  lateral  compressions  may  be  misleading  in  the  same  way. 
The  author  has  examined  endoscopically  quite  a  number  of  cases  of 
aneurysm,  and  occasionally  has  been  able  to  make  a  diagnosis ;  but  as  a 
rule,  he  does  not  regard  either  bronchoscopy  or  esophagoscopy,  when 
negative,  as  reliable  a  means  of  diagnosis  as  the  fluoroscope.  He  does 
not  advocate  endoscopy  as  a  means  of  diagnosis  of  esophageal  disease 
until  after  aneurysm  has  been  excluded  by  the  fluoroscope  and  the  well 
known  clinical  methods.  Kahler  advises  the  relief  of  dyspnea  in  aneurys- 
mal compression  of  the  trachea  or  bronchi,  by  bronchoscopic  dilatation. 
Von  Eicken  disagrees  with  this  view,  as  does  also  Taimz.  Mr.  Waggette 
(Rib.  oG7  )  rejjorts  the  obser\ation  of  the  wall  of  an  aneurysm  which 
had  caused  absor])tion  of  the  tracheal  rings. 

I. lies  of  the  triichcD-bronchial  tree.  Considering  the  frequencv  of 
luetic  lesions  in  the  larynx  their  rarity  in  the  lower  air  passages  is  re- 
niark;ib!e.  Tossibly  they  are  more  frequent  than  supposed.  The  author 
has  seen  a  fev\-  cases  (Bib.  243^,  and  other  bronchoscopists  ( \'on  Eicken, 
Kahler )  many  more.  The  lesions  may  be  gummatous,  ulcerative,  or 
innanimatory  or  may  be  compressive  granular  masses.  Excision  of  the 
margin  of  ulcers  or  fungations  for  biopsy  is  advisable,  and  in  anv  event 
the  therapeutic  test  and  the  exclusion  of  tuberculosis  will  be  required  for 
confirmation.  Ilenioptysis  in  three  cases  pre\i(iusl\-  diagnosticated  as 
tuberculous  was  found  bv  the  auth<ir  t'l  come  from  a  lentic  lesion  in  the 
lower  air  passages. 

Bronchoscopy  in  tiihrrciiinsis  of  the  tiacheo-hroiniiial  tree.  It  is 
much  to  be  regretted  that  tuberculosis  has  not  received  the  amount  of 
endoscopic  study  that  the  scientific  value  of  the  data  thus  obtainable 
would  warrant,  'i'lie  author's  own  observations  lead  him  to  describe  the 
following  endoscopic  picture  below  the  larynx.  The  subglottic  infiltra- 
tions from  extensions  of  laryngeal  disease,  are  usually  of  edematous 
appearance  but  are  much  mure  tlrni  than  in  ordinary  inflammatory 
edema.  L'lcerations  in  this  region  are  rare  unless  the  direct  extension 
of  ulceration  above  the  cord.  The  tracliea  is  but  seldom  involved  com- 
pared to  the  deeper  structures,  but  we  may  ha\e  in  the  trachea,  the  pale 
swelling  of  the  earlv  stage  of  a  perichondritis,  the  ulceration  following 
the  breaking  down  of  such  a  chondritis  and  all  the  phenomena  following 
the  mixed  infections.  These  same  conditions  may  exist  in  the  bronchi. 
In  a  number  of  instances  the  author  has  seen  a  cheesy  deposit  filling  the 
entire  luiuen  (jf  the  bronchus  which  was  occluded  by  cheesy  pus  anil 
debris  of  a  peribronchial  gland  which  had  eroded  through.  The  mucosa 
of  tuberculosis,  as  a  rule,  is  pale  and   ibi-  pallor  is   ;iccentuate<l   by   the 


486  BRONCHOSCOPY  IN  DISEASES  OF  TRACHEA  AND  BRONCHI. 

rather  bluish  streak  of  vessels  where  these  are  visible,  as  they  sometimes 
are.  Erosion  from  peri-bronchial  or  peri-tracheal  lymph  masses  may 
be  surrounded  by  granulation  tissue  of  pale  color  or  occasionally  reddish 
and  sometimes  streaked  with  blood.  A  most  common  picture  in  tubercu- 
losis is  a  broadening  of  the  carina,  which  may  be  so  marked  as  to  ob- 
literate the  carina  and  to  bulge  inward,  producing  deformed  lumina  in 
both  bronchi.  Sometimes  the  himina  are  crescentic,  the  concavity  of 
the  crescent  being  internal,  that  is,  toward  the  median  line.  Absence 
of  the  normal,  anterior  and  downward  movement  of  the  carina  on 
deep  inspiration  is  almost  pathognomonic  of  a  mass  at  the  bifurcation, 
and  such  a  mass  is  usuallv  tuberculous,  though  it  mav  be  malignant,  and, 
rarely,  luetic.  The  author  had  thought  that,  considering  the  frequency 
of  involvement  of  the  upper  lobe  bronchus,  pus  should  be  found 
draining  from  this  bronchus  as  a  rather  frequent  occurrence :  but  he  has 
rarely,  in  a  case  of  tuberculosis,  seen  any  secretion  coming  from  the 
upper  lobe  bronchus.  Possibly  the  explanation  may  be  that  drainage  by 
cough  and  gravity  had  already  removed  secretion  from  the  upper  lobe, 
or  it  may  be  that  further  observation  may  prove  this  experience  excep- 
tional. The  onl\'  lesion  visible  in  a  tulierculous  case  may  be  cicatrices 
from  healed  processes.  The  author  has  seen  one  case  of  adventitious 
dk'crticuiiim  in  the  left  bronchus  immediately  below  the  bifurcation. 
The  mucosa  seemed  quite  cicatricial  and  it  seemed  probable  that  there 
had  been  a  sujjpurative  process  associated  with  glands  in  the  mediastium 
at  the  bifurcation.  There  was  no  active  tuberculous  lesion  at  the  time, 
but  a  radiograph  by  George  W.  Grier  showed  a  mass  of  glands  at  the 
bifurcation  and  calcareous  glands  in  other  locations.  Tuberculosis  may 
almost  entirely  destroy  the  lungs  of  children  without  objective  signs.  In 
one  such  case  seen  with  Dr.  Baldwin  the  left  bronchus  was  occluded 
with  cheesy  material  and  autopsy  showed  extensive  tuberculosis  of  both 
lungs.  Yet  the  patient,  a  fourleen-months-old  infant  with  thymic  tracheal 
compression  had  never  been  ill,  nor  had  any  rise  of  temperature  ever 
been  noted. 

Hemoptysis.  Endoscopy  may  afford  the  only  means  of  locating 
and  diagnosticating  the  source  of  hemoptysis.  Manifestlv  endoscopy 
is  not  indicated  in  the  hemorrhages  of  manifest,  advanced  pulmonary 
tuberculosis.  Rut  in  the  not  inconsiderable  number  of  cases  in  which  per- 
sistent spitting  of  blood  occurs  in  the  absence  of  any  objective  signs  of 
tuberculosis  and  there  is  serious  doubt  as  to  the  source  of  hemorrhage, 
the  doubt  may  be  settled  definitely  by  bronchoscopy.  If  the  blood  comes 
from  the  air  passages,  it  will  be  noted  that  there  is  an  iiUerarytenoid 
blood  stream  brought  by  the  cilia  up  along  the  posterior  wall  of  trachea 
ruid   out   over   the   iiUerarytenoid    space,   like    the    pouring   of   a   narrow 


HRONCHOSCOPY  IN  DISEASES  OE  TRACHEA  AND  BRONCHI. 


487 


stream  of  water  out  of  the  pitcher  mouth,  giving  a  curiously  appropriate 
justification  for  the  naming  of  the  arytenoid.  This  stream  can  be  fol- 
lowed to  its  source  witli  the  bronchoscope.  In  a  number  of  the  au- 
thor's cases  (Bib.  '2-i'^)  the  source  of  the  blood  has  been  a  tuberculous 
lesion.  In  other  cases  malignanc\-  has  been  found.  \  arix  of  the  trachea 
was  the  source  in  one  of  Ephraim's  cases.  Aneurysm  has  been  found 
endoscopically  in  a  number  of  cases  of  hemoptysis.  The  author  has 
found  a  luetic  lesion  in  three  such  cases. 


C  1) 

Fig.  409. — Endoscopic  views  of  the  bronchi  in  pneumothorax  in  a  girl  of  nine- 
teen years.  A,  left  main  bronchus.  B,  same  just  above  the  giving  off  of  the 
upper  lobe  bronchus.  C,  inferior  lobe  (stem)  bronchus.  D,  orifices  of  inferior 
lobe  branch  bronchi. 


Fncitmothorax.  The  author  has  had  three  opportunities  of  exam- 
ining the  bronchi  in  jineumothorax.  The  endoscopic  images  in  one  case 
are  represented  by  the  autiior's  drawings  reproduced  in  Fig.  40!).  The 
author  can  easily  understand  how  such  lumina  might  be  produced  with 
the  excejjtion  of  C  (Fig.  lO'.M,  which  .seems  to  him  unexi)lainable,  unless 
it  was  due  to  absence  of  cartilage  at  that  point.  In  the  second  case  a  simi- 
lar concentric  diminution  of  lumen  was  noted  in  another  location,  name- 
ly the  right  inferior  lobe  bronchus.  In  the  third  case  no  such  lumen  could 
be   found. 


488  BKOXCHOSCOPY  ]X  DISKASKS  01^  TRACIIKA  AND  BRONCHI. 

The  mucosa  in  all  was  dark  pink,  but  not  cyanotic,  in  color.  The 
rings  did  not  show.  The  main  bronchus  was  collapsed  from  a  point  a 
little  below  the  bifurcation. 

Angioneurotic  edema.  The  author  has  not  been  so  fortunate  as  to 
observe  a  case  of  angioneurotic  edema  in  the  trachea,  but  it  has  been  seen 
endoscopically  by  Halstead  and  others.  In  Halstead's  case  the  edema  of 
the  bronchial  wall  produced  bronchial  dyspnea  in  a  girl  of  fifteen  years. 
The  endoscopic  picture  was  a  pale,  evenly  swollen  mucosa  producing 
stenosis. 


CHAPTER     XXX. 

Diseases  of  the  Esophagus. 

I'rior  lo  llic  ilcxelnpnicnt  of  esopliagoscopy,  diseases  of  the  esophagu-: 
could  be  studied  only  autoptically,  little  was  known  and  local  treatment 
was  ineftective  and  very  dangerous.  It  is  no  more  justifiable  to  treat  an 
eso])hagus,  or  to  ignore  esophageal  symptoms,  without  an  esophagoscopy, 
than  it  is  to  treat  a  i)atient  with  uterine  symptoms  without  local  examina- 
tion. I'ntil  recently  the  esophagus  was  being  treated  like  the  uterus  was 
in  the  author's  student  days,  w-hen  the  family  physician  regarded  local 
uterine  examination  as  a  fussv  ])reter.sion  bordering  on  quackery. 

The  classification  of  esophageal  diseases  into  stenotic  and  non- 
stenotic  is  purely  arbitrary,  since  all  diseases  of  the  esophagus  may  develop 
stenosis,  and  stenotic  diseases  are  usuallv  not  stenotic  in  their  earlier 
stages.  Paralysis,  while  not  stenotic  in  the  sense  of  a  constriction,  is 
clinically  a  stenosis  l)ecause  the  patient  cannot  swallow  even  liijuids. 
Nevertheless  the  terms  "stenotic"  and  "non-stcnotic"  arc  conxciricnt.  and 
with  the  foregoing  limitations  on  their  meaning  they  will  be  herein  used. 

Diagnosis.  The  deductive  methods  of  pre-esophagoscopic  days,  be- 
ing inconclusive  and  more  often  wrong  than  right,  are  now  entirely  super- 
sedcfl.  Diagnoses  are  now  made  esop'iag(jscopically  with  all  the  certainty 
of  direct  inspection  su])plemented  by  bioi)sy  when  needed. 

Radiography  and  fliioruscohy  in  diagnosis  of  esophageal  diseases  are 
of  the  utmost  importance  and  the  roentgenologist  and  the  esoi)hagosco- 
pist  are  working  together,  each  supplementing  the  other  in  many  ways,  as 
mentioned  imder  the  various  diseases.  Radiography  and  fluoroscopy 
during  the  swallowing  of  an  emulsion  of  some  substance  opaque  to  the 
ray  are  of  the  utmos  importance  in  the  study  of  diseases  of  the  esophagus 
and  the  esophagoscope  in  no  way  lessens  the  necessitv  of  careful  radio- 
gra]>liy  and  rtuoroscoi)y  which  should  be  i)reliniinaries  to  e\ery  eso- 
phagosco]jy.     They  should  go  hand  in  hand. 

Indications  for  esopliagoscopy  in  disease.  .Any  almcirnial  sensation, 
referable  to  the  region  or  to  the  functions  of  the  cso]ihagns,  noticed  by 


490  DISEASES  OF  THE  ESOPHAGUS. 

the  ])atient  calls  for  immediate  esophagoscopy.  Only  in  this  way  can  we 
hope  to  discover  diverticula,  esophagitis,  lues,  esophagismus,  cardiospasm, 
superficial  ulcer,  and  other  curable  lesions  in  time  to  cure.  Any  sensation 
such  as  "a  lump  rising  in  the  throat,"  the  so-called  "globus  hystericus.'" 
calls  for  esophagoscopy,  for  the  reasons  given  under  "Spasmodic  Sten- 
osis.'' In  the  absence  of  any  symptoms  whatever,  it  is  advisable  to  make 
an  exploratory  esophagoscopy  in  cases  of  tracheal  or  high  bronchial  or 
peri-bronchial  mediastinal  disease  for  the  possibilities  of  information  as 
to  periesophageal  diseases.  In  the  absence  of  any  esophageal  or  tracheo- 
bronchial evidence  of  disease,  esophagoscopy  is  indicated  in  any  case  of 
unexplained  mediastinal  radiographic  shadow.  The  symptoms  of  eso- 
phageal disease  are  so  often  stomachal  in  character  that  any  obscure 
stomach  case  requires  esophagoscopy,  and  there  is  the  added  incentive 
that  the  left  two-thirds  of  the  stomach  can  be  examined  at  the  same  time 
with  the  same  instrument  and  with  no  more  difficulty,  in  any  case  with- 
out esophageal  stenosis.  The  pyloric  third  of  the  stomach  can  be 
examined  in  only  a  few  cases.  The  most  common  form  of  confusion  be- 
tween gastric  and  esophageal  diseases  is  for  a  patient  to  comi)lain  of  vom- 
iting when  reallv  he  regurgitates.  Esophageal  spasm  is  often  caused  by 
organic  or  functional  disease  of  the  stomach.  The  gastroenterologist  and 
the  endoscopist  are  working  together  with  mutual  benefit. 

Contraindications  to  esophagoscopy  are  in  some  instances  depend- 
ent upon  lack  of  skill  on  the  part  of  the  esophagoscopist.  The  trained 
and  skillful  may  examine  any  case  of  general  or  local  disease  with  rela- 
tively little  risk,  while  in  the  hands  of  the  rough,  the  careless  or  the  un- 
trained, the  esopliagoscope  is  a  dangerous  and  frequently  fatal  instrument. 
The  dangers  are  in  inverse  ratio  to  the  skill,  and  are  multiplied  by  the  ex- 
istence of  wall-weakening  esophageal  disease.  While  the  author  would 
not  hesitate  to  advise  esophagoscopy  in  a  patient  with  aneurysm  or  very 
hard  arteries,  or  in  one  with  extensive  esophageal  varicosities,  advanced 
organic  disease,  or  extensive  acute  necrotic  or  corrosive  esophagitis,  if 
there  were  very  urgent  necessity  for  it ;  yet,  esophagoscopy  can  be  indi- 
cated in  such  a  case  only  by  very  urgent  conditions,  such  as  the  lodgment 
of  a  foreign  body.  If  there  is  anything  to  be  gained  by  it,  a  careful  esoph- 
agoscopy may  be  undertaken  by  the  trained  hand  and  eye  which  will 
stop  the  procedure  when  an  abnormal  tissue  which  must  not  be  passed  or 
even  touched  is  encountered.  In  acute  esophagitis  fr(jm  the  swallowing  of 
corrosives  it  is  better  to  defer  the  esophagoscopy  until  sloughing  has 
ceased  and  inflammatory  infiltration  has  bulwarked  the  weak  places. 
Either  extreme  of  age  is  no  contraindication  to  esophagoscopy.  The  au- 
thor has  esophagoscoped  a  number  of  new-born  infants,  consequently 
cannot  agree  with  his  distinguished  colleague,  Guisez,  that  "esophagoscopy 
is  inai)plicable  at  this  age." 


DISEASI'S  OF  THK  KSOPIIACUS.  491. 

U'att-y  hunger  is  one  of  the  most  urgent  contraindications  to  esoph- 
agoscopy.  This  condition,  which  makes  the  patient  a  very  bad  surgical 
subject,  does  not  seem  to  be  recognized  by  the  profession. 

Patients  that  have  been  able  to  get  but  little  liquid  down  for  a 
number  of  days,  frequently  come  to  the  endoscopist  and  it  is  the  au- 
thor's custom  always  to  have  a  surgeon  in  readiness  on  arrival  of  the 
patient  to  iiave  a  gastrostomy  done  immediately,  should  the  patient  prove 
to  he  in  a  serious  state  of  water  hunger.  In  the  less  severe  cases  water 
is  introduced  into  the  circulation  by  hypodermoclysis  and  enteroclysis 
simultaneously,  and  in  the  cases  on  which  gastrostomy  is  done  these  meas- 
ures are  carried  out  while  the  operation  is  being  done.  There  are  few 
conditions  other  than  spasmodic  stenosis  and  foreign  bod)-  occlusion  that 
are  so  quickly  relievable  that  gastrostomy  will  not  be  needed  anyway,  and 
it  is  better  to  do  the  gastrostomy  first  and  make  the  diagnosis  afterward. 
Some  ])atients  are  so  far  gone  when  they  arrive  that  they  die  in  spite  ot 
[)rompt  enteroclysis.  hypodermoclysis  and  gastrostomy.  It  seems  that 
when  they  get  beyond  a  certain  point  they  are  hopeless.  This  point  is 
reached  in  from  three  to  six  days,  dependent  upon  the  weather  and  upon 
whether  the  patient  had  or  did  not  have  an  abundant  supply  of  fluids 
prior  to  the  com])lcte  occlusion.  Of  course  the  time  in  which  death  may 
occur  from  water  starvation  may  be  prolonged  by  rectal  feeding. 

Gastrostomy,  as  indicated  above,  should  always  be  done  in  stenotic 
diseases  of  the  esophagus  before  the  patient  begins  to  suffer  for  either 
food  or  water.  Like  tracheotomy  it  should  be  done  early  rather  than 
late.  If  done  early,  gastrostomy  is  attended  witli  a  mortality  of  less  than 
one  per  cent,  and  as  a  life  saving  measure,  it  is  of  the  utmost  importance. 
Gastrostomy  is  advisable  in  some  instances,  even  when  the  patient  can 
swallow  liquids,  for  the  purpose  of  putting  the  esophagus  at  rest.  True, 
secretions  will  still  drain  down  the  esophagus  but  these  do  not  stagnate 
and  macerate  like  food,  even  ii(|iiid  food,  does. 

Rectal  feeding.  The  water  from  nutrient  cnemeta  is  absorbed  rather 
readily  and,  if  carefully  watched  and  faithfully  and  i)ersistently  carried 
out  in  small  continuous  dosage,  will  supply  the  system  with  fluids  and 
postiione,  for  a  long  time,  death  liy  water  starvation;  but  fur  nutrient 
pm-iioses  rectal  alimentation  is  dangerously  incflicieiit. 

Indirect  e.V(iiiii)ialion  af  esx/^hiKieal  eases.  The  larynx  and  pharynx 
should  be  examined  in  all  cases  of  suspected  esoi)hageal  disease.  I^aryn- 
geal  disease  involving  the  e[)iglottis,  arye])iglottic  folds,  arytenoids  or 
yiarty-wall  may  be  tluis  found  to  account  for  all  the  symptoms  and  may, 
in  some  cases,  negative  esophagoscopy.  It  is  characteristic  of  anv  form 
of  esopli.'.geal  stenosis,  if  of  a  severe  type,  that  both  jiyrifcn'm  sinuses 
will  be  full  of  fluid  in  the  erect  posture  of  the  patient.  The  cause  of  this 


4d2  disi:asi:s  of  the  esophagus. 

is  that  the  fluids  which  normally  are  continually  flowing  away  through 
the  esophagus,  are  unable  to  escape  downward  in  stenotic  cases,  and  thus 
the  pyriform  sinuses  fill  for  want  of  normal  drainage.  This  condition  is 
known  as  the  author's  sign  and  is  diagnostic  of  a  high  degree  of  eso- 
phageal stenosis.  Levy  has  called  the  author's  attention  to  an  exception 
to  the  ])athognomv  of  this  sign  in  advanced  cases  of  laryngeal  tuberculosis 
in  which  the  pain  of  swallowing  is  so  great  that  swallowing  is  deferred 
as  long  as  possible.  Possibly  also  there  is,  in  some  such  cases,  an  eso- 
phageal stenosis  due  to  spasm  of  the  cricopharyngeus,  a  reflex  from  the 
painful  laryngeal  lesion. 

Technic  of  esopliagoscopy  for  diseases.  The  introduction  of  the 
esophagoscope  has  been  fully  considered.  The  esophagoscope  should  in 
every  case  be  passed  by  sight.  Danger  of  perforation  and  of  overriding 
the  disease  by  mandrin  introduction  renders  the  introduction  by  sight 
the  only  method  worthy  of  consideration.  Xo  anesthesia,  general  or  local, 
is  needed,  as  explained  in  Chapter  l\',  though  local  anesthesia  of  the 
laryngopharynx  is  unobjectionable  in  adults  if  desired.  The  position 
should,  preferably,  be  recumbent  as  explained  in  Chapter  \T.  For  the 
diagnosis  and  treatment  of  diseases  of  the  upper  end  of  the  esophagus, 
the  esophageal  speculum.  Fig.  'i^ .  is.  in  the  author's  experience,  the  most 
serviceable  instrument.  It  can  be  used,  if  desired,  in  the  recumbent  or 
sitting  position  of  the  patient  as  described  in  Chapter  X. 

.\NOMALIES  OF  THE  ESOPHAGUS. 

Congenital  malformations  of  the  esophagus  may  be  divided  into 
imperforation,  stenosis,  and  esophago-tracheal  fistula. 

Imperforate  esophagus.  So  far,  the  author  has  not  had  an  oppor- 
tunity of  passing  the  esophagoscope  on  a  case  of  imperforate  esophagus, 
but  he  has  passed  the  esophagoscope  on  (|uite  a  number  of  infants,  the 
youngest  being  two  days  old.  It  was  suspected  in  this  latter  case  that  an 
imperforate  esophagus  existed,  but  on  esophagoscop)',  the  lumen  of  the 
esophagus  was  found  perfectly  normal  all  the  way  to  the  stomach.  The 
disappearance,  after  the  passing  of  the  esophagoscope,  of  the  difticulty 
in  swallowing  would  seem  to  indicate  spasmodic  origin.  When  examined 
ff)ur  months  later  by  Dr.  .Manchester  the  child  was  still  swallowing  per- 
fectly. In  view  of  this  case,  and  of  many  others  on  children  from  a  few 
days  to  a  few  months  of  age,  the  author  must  disagree  with  Guisez  in  the 
statment  that  "esophagoscopy  is  inapplicable  at  this  age."  An  esopli- 
agoscopy can  be  done  in  the  new-born  with  perfect  safety,  provided  a 
very  small  tube  be  used,  and,  provided,  of  course,  it  be  with  a  proper 
degree  of  care.  The  most  usual  site  of  the  occlusion  is  in  the  mediastinal 
esophagus,  the  upper  esophageal  segment  ending  in  a  lilind  pouch,  usual- 


DISEASKS  OF  Tin;  ESOPHAGUS.  493 

iy  more  or  less  ililatcd.  A  fistula  may  exist  between  the  lower  segments 
of  the  anomalous  esophagus,  the  upper  segment  being  injierforate. 
(Guthrie  and  Edington,  Bib.  135.) 

Congenital  csopluu/otraclical  tisliilac  are  the  most  frequent  anomaly. 
They  are  due  to  embryonic  developmental  errors.  So  far,  no  cases  of 
esophagoscopic  examination  of  congenital  tracheo-esophageal  fistulae 
have  been  reported,  but  as  the  procedure  is  safe  and  simple,  doubtless  ob- 
servations will  be  made.  In  the  case  of  a  nursling  of  six  months  of  age 
which  fell  under  the  author's  care,  a  tracheo-esophageal  fistula,  due  to 
ulceration,  would  never  have  been  suspected  had  not  the  parent  suspected 
foreign  body,  which  was  found  on  radiographic  examination  and  was  re- 
moved by  the  author.  There  was  no  suspicion  on  the  part  of  the  parents, 
nor  of  the  physicians  who  examined  the  patient  prior  to  Dr.  Sullivan,  of 
any  ditticulty  in  swallowing.  The  parents  were  concerned  solely  with. 
their  observation  that  "the  baby  coughed  until  it  vomited''  and  the  child 
undoubtedly  had  a  broncho-pneumonia.  In  a  fistula  in  the  new-born, 
there  might  be  nothing  to  lead  one  to  suspect  difticulty  in  swallowing,  and 
doubtless,  cases  of  congenital  fistula  have  been  buried  under  an  erroneous 
diagnosis.  Some  of  the  rare  cases  of  tracheo-esophageal  fistula  without 
atresia  probably  live  for  some  time,  because  some  of  the  food  escapes 
l)ast  the  fistula  into  the  stomach. 

Cougciiitii!  stricture  uf  the  esophagus  may  be  more  fre(|uent  than 
heretofore  sui)pf)sed.  Cases  are  encountered  bv  the  esophagoscopist 
where  the  |)atient  has  had  more  or  less  difficulty  in  swallowing  which  is 
often  described  as  "not  swallowing  as  well  as  other  peo])le."  \'ery  often 
these  cases  have  more  or  less  frecpient  intervals  of  exacerl)atic)n  of  their 
sym[)toms  when  the  swallowing  difficulty  becomes  quite  troublesome.  On 
esophagoscopy,  such  cases  show  a  moderate  stenosis  which  does  not  seem 
to  be  cicatricial,  and  yet  is,  ne\  ertheless,  an  organic  stenosis  not  due  to 
compression.  There  is  a  strong  sus])icion  that  such  cases  may  be  in 
some  instances  due  to  the  swallowing  of  caustics  in  cliil(lhoo<l,  but  in  the 
absence  of  any  such  history,  the  parents  being  intelligent,  it  seems  justi- 
fiable, to  class  them  as  congenital.  A  very  interesting  suggestion  is  made 
by  .X.  Brown  Kelly  (Bib.  30;i)  ;  namely,  that  stenosis  of  the  esophagus 
l)n)ducing  no  symptoms  until  early  adult  life  may  nevertheless  be  con- 
genital, since,  as  demonstrated  by  Mavlard,  congenital  narrowing  of  the 
jjylorus  rarely  manifests  itself  before  early  adult  life.  The  suggestion  of 
ISrown  Kelly  would  explain  those  rare  cases,  of  which  every  esopliagos- 
co])ist  of  experience  has  seen  a  few  in  which  there  is  an  obvious  stenosis 
of  the  esophagus,  non-cicatricial  and  certainly  non-spastic,  first  produc- 
ing .symptoms  after  adolescence.     iMutlur  data  are  to  be  hoped  for. 


491  DISEASICS  OF  THK  liSOPHAGUS. 

IVebs  in  the  upper  third  of  the  esophagus  have  been  observed.  The 
author  has  found  that  in  any  case  where  the  presence  of  a  web  is  sus- 
pected, the  best  method  of  determination  is  to  put  the  esophagus  on  the 
stretch  with  a  very  large  esopliagoscope,  or,  preferably,  with  the  eso- 
phageal speculum  shown  in  Fig.  "21.  Retraction  of  the  anterior  wall  of 
the  esophagus  will  stretch  the  web  quite  thin,  and  it  is  ver}-  easy  to  pass 
an  alligator  forceps  through  the  narrowing  and  then  withdraw  the  for- 
ceps which  are  spread.  This  will  dilata  the  constricted  lumen  due  to  the 
web,  and  if  carefully  done,  the  procedure  is  entirely  harmless.  It  is  wise 
to  pass  the  speculum  every  alternate  day  until  healing  is  complete. 
Smaller  webs  with  larger  esophageal  lumen  may  be  stretched  by  passing 
the  esophageal  speculum  without  the  use  of  any  other  dilating  instrument. 
Unlike  cicatricial  strictures,  the  web  has  very  little  tendency  to  vicious 
cicatrization  and  reproduction  of  the  stenosis. 

Treatment  of  esophageal  anomalies.  Unfortunatelv  there  is  not  often 
an  opportunity  for  treatment.  Gastrostomy  is  indicated  in  imperforate 
cases.  Esophagoscopy  has  nothing  remedial  to  ofifer  except  in  cases  of 
stricture  and  webs.  Strictures  can  be  dilated,  but  even  more  care  should 
be  exercised  here  than  in  cicatricial  strictures.  The  few  probably  congen- 
ital cases  the  author  has  seen  yielded  more  promptly  than  cicatricial  sten- 
oses of  the  same  size  of  lumen  and  had  less  tendency  to  contract.  In  none 
of  the  cases  was  the  full  size  of  the  esophageal  lumen  restored,  but  the 
patients  remained  free  from  dysphagia.  \\'ebs  are  very  successfully  dealt 
with  as  already  mentioned. 

Rupture  and  trauma  of  tlie  esophagus  may  be  spontaneous  or  may 
result  from  the  trauma  of  an  instrument  or  of  a  foreign  body,  or  of  both 
combined,  as  was  frequently  the  case  in  the  old  days  of  blind  attempts 
at  pushing  a  foreign  body  downwards.  MacReynolds  reports  a  case  of 
spontaneotts  rupture  of  the  esophagus  following  extensive  ulceration  of 
the  esophageal  wall.  The  patient  had  been  operated  upon  for  an  uncom- 
plicated mastoiditis.  The  death,  some  days  after  operation,  was  found  at 
post  mortem  to  be  due  to  ])rofuse  hemorrhage  following  rupture,  which 
was  in  the  lower  third.  Xo  unusual  strain  had  been  put  upon  the  esoph- 
agus and  no  solid  food  had  been  taken  for  a  week.  Rupture  of  the 
esophagus  is  usually  attended  with  mediastinal  emphysema,  profound 
shock,  a  weak  rapid  pulse,  restlessness,  fever  and  rapid  sinking.  If  the 
pleura  has  been  torn,  as  is  frequently  the  case,  the  symptoms  and  physical 
signs  of  ]>neumothorax  are  added.  In  such  cases  tapping  of  the  pleural 
cavity  will  usually  obtain  a  small  amount  of  fluid  with  fecal  odor.  Lesser 
degrees  of  trauma  not  perforating  all  the  layers  of  the  esophageal  wall, 
may  show  slight  symptoms  of  esophagitis  (q.  v.).  The  early  endoscopic 
appearances  of  esophageal  trauma  are  those  of  a  bleeding  laceration  of 


DISEASES  OF  THE  ESOPHAGUS.  495 

the  mucosa.     Later  int1ammat(jr\'  and  ulcerative  a]>i>earaiices   (  q.  v.)   arc 
manifest. 

The  treatment  of  trauma  without  perforation  is  the  same  as  for 
acute  esophagitis  {<.\.  v.).  The  traumatism  due  to  the  foreign  body  itself 
is  almost  invariably  e.xceedinglv  slight  and  does  not  penetrate  deeply  and 
heals  promptly.  Jjlind  methods  of  removal,  however,  are  often  attended 
with  serious  and  fatal  traumatism.  The  food  in  any  case  should  be  sterile 
liquids  only,  and  all  water  should  be  sterilized  and  served  sterilly.  Rup- 
ture of  the  esophagus  demands  immediate  gastrostomy  (under  local  an- 
esthesia )  to  nourish  the  patient,  to  supply  him  with  fluid,  and  to  put  the 
esophagus  at  rest.  If  the  pleura  has  been  ruptured  immediate  thoracot- 
omy, with  insertion  of  a  drain  at  the  most  favorable  point  of  drainage, 
may  save  life,  which  without  this  procedure,  is  hopeless.  Stimulation, 
hot-water  bags,  elevation  of  the  foot  of  the  bed,  atropine  and  other  shock 
combating  methods  are  indicated.  The  patient's  head  should  be  low 
and  the  mouth  turned  toward  the  pillow  to  lessen  the  drainage  of  se- 
cretions into  the  esophagus. 

INFLAMMATION    .\ND   UECEKATION   OF   THE   E.SOPHAGUS. 

Acute  esophagitis  is  usually  of  traumatic  or  cauterant  origin.  If 
severe  or  extensive,  all  the  symptoms  described  under  "Rupture  of  the 
Esopliagus"  may  be  present.  The  endoscopic  appearances  are  unmistak- 
able to  anyone  familiar  with  the  appearance  of  nuicosal  inflammations. 
The  pale,  bluish  pink  color  of  the  normal  mucosa  is  replaced  by  a  deep 
red  veK'ety  swollen  ajjpearance  in  which  individual  vessels  are  invisible. 
After  exudation  of  serum  into  the  tissues,  the  color  mav  be  paler  and 
in  some  instances  a  typical  edema  may  be  seen.  This  may  diminish  the 
lumen  tem])orarily.  If  the  inflammation  is  due  to  corrosives,  a  grayish 
exudate  may  be  visible  early,  sloughs  later. 

i'lceration  of  the  csopha(jiis.  In  the  main,  the  observations  of  the 
author  in  his  earlier  volume  ( l!ib.  '^ii!i )  have  been  fully  borne  out  by 
further  experience.  W'liile  ulceration  of  the  eso])hagus  cannot  be  said  to 
be  a  common  disease,  yet  those  who  examine  the  esophagus  constantly, 
meet  with  occasional  cases.  Superficial  erosions  are  by  no  means  un- 
common, and  the  condition  of  inflammation,  at  times  associated  with 
erosion  and  even  with  ulceration,  that  accom])anies  the  stagnation  of  food, 
is  a  very  important  part  of  the  pathology  of  esophageal  stricture.  Lender 
the  head  of  spastic  stenoses,  the  author  has  described  the  condition  as  con- 
stituting a  "vicious  circle"  wherein  spastic  stenoses,  w-hether  due  primar- 
ily to  esophagitis  or  other  local  lesion  or  not,  excite,  or  at  least  perpet- 
uate an  eso])hagitis,  which,  in  turn,  is  a  factor  in  the  production  of  the 
spastic  stenosis.    The  more  constant  the  spastic  condition,  necessarily  the 


496  DISEASES  OF  THE  ESOPHAGUS. 

greater  the  degree  of  esophagitis.  The  author  has  met  with  a  number  of 
cases  of  manifestly  cicatricial  stenosis,  which,  from  the  history,  seem  to 
have  resulted  from  such  a  condition.  There  had  been  no  history  of  swal- 
lowing any  corrosives  in  childhood,  and  the  esophageal  trouble  came  on 
comparatively  late  in  life  so  that  any  accidental  cause  for  the  production 
of  a  cicatricial  stricture  would  necessarily  have  been  remembered  by  the 
patient.  One  case  of  ulceration  of  the  esophagus  observed  by  the  author 
deserves  special  mention : 

A  girl,  aged  two  xears.  was  brought  to  the  author  by  Dr.  L.  C.  Man- 
chester for  ditiiculty  in  swallowing  which  had  come  on  during  an  attack 
of  aphthous  stomatitis.  The  child  had  been  listless  and  had  refused  to  eat. 
Temperature  102-  F.  (39°  C).  It  had  been  thought  that  it  refused  to 
swallow  simply  because  of  the  pain  in  the  mouth,  but  after  24  hours  with- 
out food  or  water,  the  child  made  strenuous  efforts  to  swallow  but  the  milk 
came  back  promptly.  Upon  examination  with  the  child's  esophageal 
speculum.  Fig.  21,  the  cricopharyngeal  constriction  was  seen  to  be  the  site 
of  three  small  ulcerations.  The  T  mm.  esophagoscope  was  introduced  be- 
low these  ulcerations,  and  it  was  discovered  that  in  the  middle  third  of 
the  esophagus  there  were  two  distinct  ulcers  and  one  elongated  ulceration 
which  had  the  appearance  of  two  ulcers  having  coalesced.  Just  below 
this  were  two  small  vesicles,  each  surrounded  by  a  red  areola.  A  soft 
rubber  tube  was  introduced  and  the  child  fed.  It  was  given  a  few  drops 
of  an  alum,  sage  and  honey  mi.xture,  and  in  about  ten  days  was  entirely 
well  of  the  lesions  in  the  mouth  and  the  swallowing  was  normal.  A  sec- 
ond esophagoscopy  thirty  days  after  the  first,  showed  a  normal  esophagus. 

Remarks.  It  was  quite  evident  that  the  difficulty  in  swallowing  was 
entirely  spasmodic  as  no  stenosis  was  found  and  the  esophagoscope  met 
with  no  obstruction  in  passing  all  the  way  to  the  stomach. 

Ulceration  may  follow  trauma  of  a  foreign  body,  an  instrument  or  a 
corrosion,  and,  of  cou.rse,  is  part  of  nature's  method  of  repair.  Sloughs 
may  be  present,  and  exudates  and  exfoliation  may  modify  the  endoscopic 
picture. 

Differential  diagnosis  of  nicer  of  the  esophagus.  To  recognize  the 
presence  of  an  ulcer  esophagoscopically  is  not  difficult  if  it  be  not  covered 
with  macerated  epithelial  debris,  bismuth,  food  or  secretion,  but  to  de- 
termine that  it  is  a  simple  ulcer,  requires  the  exclusion  of  lues,  tuber- 
culosis, epithelioma,  endothelioma,  sarcoma,  and  actinomycosis.  Simple 
ulcer  of  the  esophagus  is  usually  associated  with  a  stenosis,  spastic  or  or- 
ganic. In  the  absence  of  a  stenosis,  we  are  usually  justified  in  excluding 
simple  ulcer.  This  is  not  absolute  (see  case  above  cited),  but  it  arouses 
a  very  strong  suspicion  that  the  ulcer  is  either  malignant  or  luetic.  The 
characteristics  of  the  luetic  ulcer  are  the  highly  inflammatory  state  of  the 


DISEASES  CV  THE  ESOPHAGUS.  497 

surrounding  mucosa,  the  thickened  elevated  edges  usually  free  from  gran- 
ulation tissue,  with  a  somewhat  pasty  center  and  not  bleeding  readily 
when  sponged,  though  the  surrounding  mucosa  gives  one  the  impression 
of  being  intensely  vascular.  The  tuberculous  ulcer,  if  primary  in  the 
esophagus,  is  very  superficial  and  seems  to  partake  more  of  the  char- 
acter of  an  erosion  than  of  ulceration.  The  mucosa  is  pale  and  gives  one 
the  impression  of  anemia.  It  is  usually  free  from  granulation  tissue,  but 
there  mav  be  small  granular  elevations  at  different  points,  usually  rather 
scattered.  There  may  be  slight  cicatrices.  If,  however,  the  tuberculosis  is 
an  extensirjn  by  continuity  from  periesophageal  tuberculous  glands,  and 
especially  if  there  is  a  fistulous  communication  with  a  bronchus,  we  may 
have  quite  a  cauliflower  growth  of  granulations,  though  usually  they  are 
quite  pale.  In  the  cases  in  which  a  tuberculous  process  has  invaded  the 
cso])hagus  from  either  a  lung  lesion,  or  a  mediastinal  adenopathy,  there  is 
usually  such  a  manifest  tuberculous  syndrome  that  the  diagnosis  can  be 
made  therefrom.  The  tuberculin  test,  reverse  tuberculin  test,  guinea  pig 
injection  with  emulsion  of  tissue,  with  the  histologic  examination  of  tis- 
sue for  the  bacilli  and  for  the  morphologv  of  tuberculosis — all  these  taken 
together  are  almost  absolutely  decisive;  though  the  remote  possibility  ol 
a  mixed  lesion  of  tuberculosis  with  lues  or  malignancy  must  be  borne  in 
mind.  The  ulcer  of  sarcoma  does  not  differ  materially  from  the  ulcer 
of  carcinoma.  The  carcinomatous  ulcer  is  usually  characterized  by  the 
very  vascular  bright  red  zone,  raised  edges,  granulation  tissue  that  bleeds 
freely  on  the  slightest  touch,  and  above  all,  it  is  almost  invariably  sit- 
uated on  an  infiltrated  base,  which  communicates  a  feeling  of  hardness  to 
the  pressure  of  sponges  or  of  the  esophagoscopic  tube  itself.  Another 
characteristic  sometimes  seen  in  carcinoma  is  the  pointed  projections 
springing  somewhat  like  granulation  tissue  from  the  ulcer  or  its  neigh- 
borhood. A  scar  mav  be  from  the  healing  of  an  ulcer  of  simple  or 
specific  character,  or,  on  the  other  hand,  it  may  be  a  cancerous  process 
develo])ing  on  the  site  of  a  scar,  so  that  the  presence  of  scar  tissue  does 
not  absolutely  negative  malignancy.  As  a  rule,  however,  we  do 
not  see  a  scar  in  cases  of  cancer  of  the  esophagus.  In  determining  in- 
filtration, we  must  be  on  our  guard  not  to  be  misled  by  the  sensation  com- 
municated in  some  cases  by  the  ridge  ])roduccil  by  the  lett  bronchus 
where  it  crosses  the  esophagus.  In  some  cases  of  esophageal  disease  with 
dilatation,  cs|)eciall\'  if  the  stenosis  is  not  far  below  the  bronchus,  the 
ridge  protruded  by  the  crossing  of  the  bronchus  is  ai'l  to  lie  inominent 
and  feels  quite  resistant  to  the  pressure  of  the  tube.  In  some  instances 
it  is  possible  to  make  an  accurate  diagnosis  of  a  simple  ulcer  by  exclusion 
through  esophagoscopic  appearances  alone.  Usually,  however,  the  aid 
of  the  l.'iboratorv  nuist  be  invoked,  chicflv  because  lesions  occur  more  or 


408  DISEASES  OF  THE  ESOPHAGUS. 

less  mixed  in  character,  owing  to  the  fact  that  all  ulcerations  of  the  esoph- 
agus are  associated  with  mixed  infections.  The  resultant  infective  in- 
flammations give  a  uniformity  in  character  that  interferes  seriously  with 
differentiation,  because  infecti\e  inflammation  is  apt  to  produce  the  same 
esojihagoscopic  appearance  regardless  of  the  lesion  which  caused  the 
primary  solution  of  continuity.  The  foregoing  remarks  apply  only  to 
the  ulcerated  lesions  of  the  diseases  mentioned.  The  differentiation  of 
non-ulceratetl  lesions  is  elsewhere  herein  considered.  In  any  case  of  ul- 
ceration of  the  esophagus  unassociated  with  stasis,  we  are  justified  in 
pushing  the  therapeutic  test  with  potassium  iodide  and  mercurial  in- 
unctions. We  are  also  justified  in  sponging  the  surface  of  the  ulcer  with 
a  gauze  sponge ;  but  to  obtain  a  specimen,  it  is  seldom  justifiable  to  scrape 
the  ulcer,  unless  it  is  on  a  verv  much  infiltrated  base.  If  the  edges  are 
thin  and  flat,  the  taking  of  a  specimen  of  tissue  involves  some  risk.  If, 
however,  the  ulceration  has  a  thickened  elevated  edge,  this  edge  may  be 
nipped  off  with  the  tissue  forceps.  Fig.  35.  The  histologic  examination 
of  the  tissue  and  a  bacterial  examination  of  the  secretions  wiped  from  the 
face  of  the  ulcer,  should  give  accurate  information.  If  the  laboratory 
report  is  uncertain,  we  are  justified  in  repeating  the  removal  of  specimens 
of  tissue  and  secretion  a  number  of  times.  A  positive  W'assermann,  or 
luetin,  or  a  positive  luetic  history  only  makes  the  therapeutic  test  all  the 
more  strongly  indicated.  That  the  man  has  had  lues  does  not  necessarily 
mean  that  the  ulcer  in  question  is  luetic,  for  a  luetic  man  may  have  a 
malignant  growth  or  be  subject  to  tuberculosis ;  in  fact  it  is  a  serious 
question  whether  or  not  lues  i)redisposes  to  these  conditions.  Spirochetal 
findings  in  a  si)ecimen  of  tissue  is  decisive,  but  failure  to  find  is  diag- 
nostically   valueless. 

Treatment  of  acute  and  subacute  inflanunatioii  and  ulceration  of 
esophagus.  As  a  rule,  a  simple  ulcer,  associated  as  it  almost  invariably 
is  with  more  or  less  stenosis  and  stasis,  usually  yields  to  the  local  ap- 
plication of  argyrol,  with  rest  of  the  esophagus.  The  best  way  to  obtain 
this  rest  is  to  do  a  gastrostomy  for  feeding  so  that  nothing  but  secre- 
tions will  go  through  the  mouth.  The  teeth  and  mouth,  of  course, 
should  be  kept  scrupulously  clean.  If  the  ulceration  heals  by  these  means 
alone,  without  any  other  treatment  whatsoever,  we  may  be  justified  in 
concluding  that  the  ulceration  was  of  simple  character. 

In  all  forms  of  esophagitis  and  in  the  ulcerations  consequent  upon 
traumatism,  such  as  that  of  foreign  bodies,  the  usefulness  of  bis- 
muth subnitrate  has  been  ami)ly  demonstrated  by  the  author.  It  is  given 
dry  on  the  tongue  and  swallowed  preferably  without  li(|uid  in  order  bet- 
ter to  adhere  to  ulcerated  surfaces.  That  il  does  adhere,  the  author  has 
noted  in  a  number  of  cases  in  which  the  bismuth  had  been  given  ther- 


DISEASES  OF  THE  ESOPHAGUS.  499 

apeutically,  and  also  in  oases  in  wliich  it  had  been  used  in  order  to  (il)tain 
a  ray  picture  in  cases  of  esophageal  stenosis.  The  comliination  with  a 
little  calomel  given  from  time  to  time  is  excellent,  llismuth  has  quite  a 
good  deal  of  antiseptic  action,  hut  whether  this  be  the  explanation  or 
not,  empirically  the  author  has  had  abundant  evidence  that  this  treat- 
ment for  inflammation  and  ulceration  of  the  esophagus  is  curative. 
Argyrol  in  'i'>  per  cent  solution  locally  ai)plie(l  esophagoscopically  is  also 
useful  in  cases  of  ulceration,  and  especially  those  attended  with  funga- 
tions.  In  three  cases  wheve  external  operations  through  the  neck  had  in- 
volved the  esophagus,  dysphagia  was  found  by  the  author  to  be  due  to  an 
unhealed  wound  in  the  esophagus,  and  in  all  three  cases,  apjilications  of 
argyrol  resulted  in  healing. 

Chronic  cso/^liag'tis.  The  appearances  of  chronic  esophagitis  will  be 
dealt  with  in  connection  with  diffuse  dilatation  and  spasmodic  stenosis. 

Treatment  of  chronic  csofthai/ifis.  'I'he  best  treatment  for  chronic 
esophagitis  is  the  correction  of  stenoses,  organic  or  spastic,  which  exist 
below.  ]irciclucing  stasis  of  ff)od.  If  the  stenosis  is  not  completely  curable, 
local  remedies  are  of  great  aid  in  limiting  the  degree  of  inflammation. 
Jlisniuth  subnitrate  is  the  best  remedy.  Calomel  may  be  given  also  occa- 
sionally, both  of  these  being  given  dry  on  the  tongue.  The  best  local  en- 
doscopic a];plicatinn  is  argyrol  in  l."i  per  cent  solution. 

CilMI'Ki:sSI0N  STENOSIS  OE  THE  Esorii.vc.us. 

Compression  stenosis  may  be  the  result  of  any  periesophageal  disease 
or  anomaly.  The  most  fre(|Ueiit  lesions  are  thyroid  enlargement,  cervical 
or  thf)racic,  malignancv.  aneurysm,  auricular  and  aortic  enlargement,  or 
calcification,  Ixmphatic  infiltration,  lordosis.  Thoracic  compressions  are 
usually  from  mediastinal  lesions,  though  the  author  saw  one  case  of  com- 
pression b\'  a  cancerous  lung  that  had  not  \et  invoKed  the  mediastinum. 
In  an<jther  case  a  walled-off  abscess  of  the  u[)per  lobe  of  the  right  lung 
and  pleura  caused  the  com])ression  without  mediastinal  involvement.  In 
two  cases  of  the  author  comjiression  of  the  esophagus  was  due  to  ]ires- 
stire  of  a  hy])ertrophic(l  heart.  Bassler  has  reported  a  case  due  to  hyper- 
trophy of  the  auricle.  Stenoses  in  the  lower  part  of  the  thorax  are  \ery 
rarely  comjtressive.  'i'he  author  has  seen  one  such  case  associated  with  a 
pleural  fistula  \\hich  had  been  discharging  for  years  subsequent  to  sur- 
gical evacuation  of  an  empyema  so  that  the  exact  nature  of  the  compres- 
sive tissue  could  not  be  made  out.  Collier  rejwrts  a  case  of  compressive 
stenosis  from  cancer  of  the  liver  and  Cottstcin  one  from  the  pressure  of  a 
calcareous  area  in  the  pleura. 

Differential  dia(/>iosis  of  c<nnf'rcssi7r  stenoses  of  the  esofhoj/iis. 
The  existence  of  a  stenosis  is  often  indicated  by  the  .uuhor's  sign  of  se- 


500  DISEASES  OE  THE  ESOPEIAGUS. 

cretion-fiUed  pvriform  sinuses.  Compression  stenosis  covered  with  nor- 
mal mucosa,  can  be  readily  differentiated  in  most  cases  from  disease  of 
the  wall  of  the  esophagus:  but  the  nature  of  the  compressive  lesion  and 
its  extent  outward  from  the  esophagus  will  usually  require  the  aid  of  the 
roentgenologist  or  fiuoroscopist.  Compression  stenosis  is  manifested 
usually  by  a  slit-like  crevice  which  occupies  the  place  of  the  lumen  and 
which  does  not  open  up  readily  before  the  advancing  tube.  The  slit  may 
be  curved,  and  its  long  axis  is  almost  always  at  right  angles  to  the  com- 
pressive mass  if  the  esophageal  wall  be  uninvolved.  The  normal  radial 
creases  separating  the  folds  are  diminished  to  two,  one  at  each  end  of  the 
crescentic  slit-like  lumen.  The  covering  mucosa  may  be  normal  or  show- 
signs  of  chronic  inflammation  from  stasis.  If  the  esophageal  wall  is  un- 
involved the  esophagus  is  mo\alile  laterally  with  the  tube-mouth  and  the 
mucosa  can  be  readily  pushed  up  into  folds. 

Goitrous  coinpression  of  the  esophaaiis  by  a  cervical  goitre  is  readily 
confirmed  by  palpation  of  the  neck,  but  with  a  substernal  goitre  \erifica- 
tion  is  not  so  easy.  Corroboration  is  to  be  had  from  radiography.  The 
esophagus  is  not  so  often  seriouslv  compressed  as  is  the  trachea. 

Aneurysmal  couihrcssiou  of  the  esophagus.  Theoretically,  one  might 
suppose  that  the  endoscopic  picture  in  an  aneurysmal  compression 
stenosis  of  the  esophagus  must  be  expansile.  As  a  matter  of  fact,  how- 
ever, in  all  of  the  cases  that  the  author  has  observed,  the  pulsation  seems 
to  be  simply  a  transmitted  pulsation  of  the  aneurysmal  sac  acting  simply 
as  a  tumor  might  in  transmitting  the  pulsation  from  the  aorta  itself.  The 
author  has  observed,  in  many  instances,  in  abdominal  esophagismus,  a 
very  much  more  inarked  pulsation  with  w-ider  excursion  in  the  absence 
of  any  lesion,  which  coincides  with  the  observation  of  Boyce  that  cases 
of  abdominal  esophagismus  are  often  associated  with  a  \ery  much  en- 
larged aorta.  As  pointed  out  by  Sargnon  (Bib.  491  j  very  slight  degrees 
of  aneurysm  are  extremely  difficult  to  detect  either  by  physical  signs  or 
by  radiography  and  may  even  be  overlooked  at  esophagoscopy  unless  the 
most  extreme  caution  is  taken.  It  would  lie  easy  to  be  misled  into  at- 
tempting blind  biniginage  and  doubtless  this  does  happen  with  those  who 
are  not  familiar  with  the  uses  of  the  esophagoscope.  In  using  the  esoph- 
agoscope  on  such  cases  it  is  necessary,  as  Sargnon  points  out,  not  to 
go, below  any  sort  of  comjiression  or  narrowing  until  aneurysm  has  been 
excluded  by  all  available  means  including  esophagoscopic  stud\-. 

Aortic  compression  of  the  esophac/us  was  alluded  to  above  in  writ- 
ing of  aneurysm.  In  one  of  the  author's  cases  a  compression  stenosis 
was  noted  at  the  level  of  the  arch  of  the  aorta.  Radiography  revealed 
such  a  dense  irregular  shadow  of  the  aortic  wall  as  to  render  justifiable 
the  opinion  that  the  aortic  wall  was  to  a  greater  or  less  extent  calcified. 


DisEASKS  oi-  Tin;  ksophagus.  501 

The  patient  was  a  man  (ill  years  of  age.  An  examination  of  the  hterature 
revealed  a  number  of  cases,  a  most  notable  one  by  Anthony  Bassler.  A 
number  of  observers  have  confirmed  observations  of  Kovacs  and  Stoerk 
in  regard  to  the  kinking  of  the  esophagus  by  enlargement  of  the  left  au- 
ricle. The  author  has  since  observed  in  two  cases  very  marked  compres- 
sions and  deviations  from  this  cause.  In  both  cases  there  had  been  no 
symptoms  referable  to  the  esophagus  but  a  large  mass  of  meat  had  lodged 
and  was  removed  esopliagoscopically. 

Carcinomatous  and  sarcomatous  coinf^rcssions  of  the  csophai/iis  are 
characterized  by  their  hardness  when  jialpated  by  the  tube  mouth  or 
probe. 

Adenopathic  compression  of  the  csopha(/us.  !Minor  compressions 
are  often  noted,  and  the  diagnostic  and  prognostic  value  of  the  esophagos- 
copically  demonstrable  lymph  nodes  at  the  sides  of  the  esophagus  has 
been  noted  in  connection  with  cancer  of  the  larynx.  A  high  degree  of 
stenosis  may  be  due  to  a  large  mass  of  infiltrated  glands  in  the  medias- 
tinum especially  below  the  crossing  of  the  left  bronchus.  Usually  trach- 
eal, bifurcational  or  bronchial  stenosis  may  be  found  in  the  same  case. 
In  any  comjiressive  stenosis  of  the  mediastinal  esophagus  in  an  adult, 
not  clearly  malignant  nor  tuljerculous,  it  is  wise  to  give  potassium  iodid 
and  mercury,  which  must  be  pushed  to  a  full  therapeutic  test  without 
stopping  al  the  first  sign  of  iodism.  If  this  be  done,  an  occasional  cure 
will  result,  of  which  the  author  has  seen  a  number  of  instances.  Lordosis 
is  a  not  infrec|uent  cause  of  compression  stenosis  of  the  cervical  esoph- 
agus. The  prominence  of  the  posterior  wall  and  the  boay  hardness 
render  identification  easy.  It  is  doubtful  if  scoliosis  produces  any  com- 
pression or  deviation  of  the  esopha.gus.  Xo  such  cases  have  been  re- 
corded, to  the  writer's  knowledge.  The  investigations  of  H'-^ker  and 
Kollicker  render  the  occurrence  doul)tful. 

The  frequency  with  wliich  posticus  laryngeal  paralysis  is  associated 
with  compressive  esophageal  stenosis  .should  be  borne  in  mind. 

Treatment  of  compressive  stenosis  of  the  esophagus.  Curative  treat- 
ment is  necessarilv  concerned  witii  c\ire  of  tiie  compressive  lesion  and 
hence  is  not  within  the  province  of  endosco[)y.  I'nless  the  diagnosis  of 
the  nature  of  tlu-  compressive  lesion  is  certain  it  is  well  to  give  potassium 
iodid  and  tnercur\ ,  as  an  occasional  cure  of  a  gummatous  or  adenopathic 
luetic  lesion  in  a  sup|)0se(lly  malignant  or  other  case  will  occur.  Palliative 
treatment  by  esophageal  intub:ition  (q.  v.)  is  indicated  in  all  conditions 
except  aneurysm.  This  is  quite  feasible  and  satisfactory  in  many  cases 
in  which  the  ordinary  stomach  tube  cannot  be  passed.  Castrostomy 
should  be  done  earlv  when  ncccssarv. 


502  DISEASES  OF  THE  ESOPHAGUS. 

DIEFlSE  DILATATION  OF  THE  ESOPHAGUS. 

This  is  practically  always  stagnation  ectasia.  The  adherents  of  tlie 
atonic  theory  of  diffuse  dilatation  are  now  few  and  there  is  little  evi- 
dence, clinical,  anatomical,  or  physiological,  to  support  their  view.  In 
the  author's  experience,  dilatation  of  the  esophagus  has  been  invariably 
associated  with  either  organic  or  spasmodic  stricture,  existing  either  at 
the  time  of  the  observation  or  at  some  time  prior  thereto.  In  four  cases 
of  dilatation  discovered  b}-  the  author  during  gastroscopy  in  [jatients  with- 
out esophageal  symjitoms,  there  was  a  history  indicating  clearly  a  spas- 
modic stenosis  earlier  in  life.  The  action  of  the  stricture  in  causing  dif- 
fuse dilatations,  whether  the  stricture  be  spasmodic  or  organic,  is  prob- 
ably largely  due  to  deglutitory  pressure  of  accumulated  food.  Though 
gravitation  does  not  much  aid  normal  deglutition,  it  probably  aids  in  in- 
creasing a  suprastenotic  dilatation.  It  is  not  at  all  necessary  that  the  food 
should  remain  a  long  time  in  the  esophagus.  The  esophagus  seems  to  be 
constituted  on  the  basis  of  immediately  emptying  itself  of  whatever  may 
enter  it  from  either  above  or  below.  In  other  words,  it  is  intolerant  of 
the  ])resence  of  anything  excejit  its  own  normal  secretions  and  these  must 
be  in  very  small  amounts  and  continually  draining  away.  Stagnation 
even  of  secretions  will  produce  not  only  dilatation,  but  esophagitis.  If 
a  stricture  is  not  very  small  and  yet  is  sufficient  to  hokl  back  for  a  time 
what  has  been  swallowed,  the  esophagus  acts  as  a  reservoir  of  a  large 
funnel  with  a  very  small  opening.  When  food  is  swallowed,  the  esoph- 
agus fills  and  the  contents  trickle  slowly  through  the  opening.  This 
distension  is  sufficient  to  result  in  permanent  dilatation,  and  strange  to 
say,  such  dilatation  always  remains  once  it  has  been  established  (Jesse 
Mayer,  Bib.  3!)!)),  even  though  the  stenosis  which  caused  it  has  entirely 
disappeared.  It  seems  likely  that  the  gases  due  to  fermentation  of  the 
stagnant  food  may  increase  the  dilatative  pressure  beyond  what  w'ould 
result  from  mere  gravity,  because  we  practically  never  see  in  cases  of 
organic  stenosis  the  enormous  degrees  of  dilatation  seen  in  spastic 
stenoses.  Theoretically  it  would  seem  that  there  existed  in  cases  of 
hiatal  and  abdominal  esophagismus  a  spasm  also  of  the  cricopharyngeus 
and  associated  circular  esophageal  fibres,  preventing  ready  escape  of  the 
gases  upward.  As  a  matter  of  fact  many  of  the  patients  observe  a  dis- 
tress partially  relieved  at  intervals  by  the  escape  of  gas.  That  the  re- 
lief is  not  complete  is  probably  due  to  the  irritation  from  food  and  gases 
still  remaining  in  the  dilated  esophagus.  A  very  large  dilatation  of  the 
thoracic  esophagus  indicates  a  spastic  stenosis.  Cicatricial  stenoses  do 
not  result  in  such  large  dilatations,  possibly  because  of  leakage  shorten- 
ing the  duration  of  stasis.  Malignant  stenoses  do  not  exist  long  enough 
to  cause  very  large  dilatations,  though  small  ones  are  common  and  their 


DISEASES  OE  THE  ESOPHAGUS.  503 

size  is  an  indi-x  of  llu-  liiiralioii  of  the  growth;  tliough  the  possibility  of 
malignancy  develo])ing  in  a  spastic  case  must  be  remembered. 

Treatment  of  diffuse  dilatation  of  the  esophagus.  The  treatment  of 
diffuse  dilatations  that  produce  symptoms  consists  in  dilating  the  hiatal 
and  abdominal  esophagus,  even  in  cases  where  spasm  cannot  be  demon- 
strated. This  dilatation  will  relieve  the  patient  of  the  symptoms  and  of 
the  stagnation  of  food,  though  the  increased  size  of  the  esophagus  after 
dilatation  w-ill  never  disappear.  Treatment  is,  therefore,  the  same  as  if 
hiatal  or  abdominal  eso|)hagismus  could  be  demonstrated.  If  chronic 
csophagitis  is  present,  as  it  usually  is,  the  administration  of  bismuth  sub- 
nitrate  with  calomel  occasionally,  and  possibly,  in  some  cases,  the  local 
csophagoscopic  application  of  argvro'  solution,  ,'i  per  cent,  are  indicated. 


CHAPTER     XXXI. 

Diseases  of  the  Esophagus.    Continued. 

SPASMODIC    STENOSIS    OF    THE    ESOPHAGUS. 

The  aiitlior's  early  urging  of  endoscopists  to  make  a  thorough  study 
of  spasm  has  borne  abundant  fruit.  Esophageal  spasm  in  the  earlv  days 
of  endoscopy  was  considered  one  of  the  rarest  conditions,  while  to-day  it 
as.sumes  etiologically  and  pathologically,  first  place  in  importance.  The 
factor  of  spasm  enters  into  nearly  every  condition  of  the  esophagus  with 
which  the  endoscopist  has  to  deal,  even  in  foreign  body  cases  where  a 
foreign  body  of  very  small  size  may  excite  sufficient  spasm  entirely  to 
occlude  the  esophagus,  so  that  even  liquids  cannot  be  swallowed.  In 
speaking  thus  of  the  importance  of  spasm  and  its  frequency,  the  author 
does  not  allude  to  what  the  beginner  in  esophagoscopy  is  likely  to  en- 
counter. Nearly  every  beginner  thinks  in  every  case  in  which  he  has 
difficulty  in  introducing  the  esophagoscope  past  the  cricoid,  that  the  pa- 
tient has  a  spasmodic  stenosis.  It  is  not  until  introduction  has  become 
easy  that  the  endoscopist  is  able  to  determine  whether  true  spasm  exists 
or  not,  at  the  upper  end  of  the  esophagus.  Of  course,  there  is  always 
more  or  less  of  spasm  of  the  cricopharyngeus  in  every  case,  unless  the 
patient  be  very  profoundly  anesthetized ;  but  this  does  not  constitute  true 
pathologic  esophageal  spasm.  Esophageal  spasm  might  be  classified  into 
spasms  of  the  upper  end  and  those  of  the  lower  end,  for  it  is  very  rarely 
that  spasm  exists  in  the  middle  third.  The  objection,  however,  to  this  is 
that  we  cannot  always  dissociate  high  and  low  spasms,  because  they  may 
coexist  or  may  alternate  in  the  same  case.  A  disease  of  the  lower  third 
may  cause  spasm  of  the  upper  end  of  the  esophagus  and  vice  versa.  For 
this  reason  also,  the  symptoms  and  the  sensations  of  the  patient  are  not 
to  be  relied  upon.  The  patient  may  complain  of  inability  to  even  start 
food  down,  when  upon  esophagoscopy,  we  find  that  the  lesion  is  located 
at  the  cardia,  in  which  case  if  we  were  to  rely  upon  symptoms,  we  would 
expect  the  food  to  be  swallowed  and  then  regurgitated  after  a  longer  or 


DISEASES  OI-   THE  ESOPHAGUS.  505 

shorter  time.  It  is  no  woiuk-r,  tiifii,  that  httlc  progress  was  made  in  the 
study  of  the  diseases  of  the  esophagus  prior  to  recent  general  use  of  the 
esophagoscope.  Without  underestimating  the  very  valuable  results  to  be 
had  from  radiography,  it  must  be  said  that  only  by  esophagoscopy  can 
the  exact  nature  of  lesions  be  determined  without  grave  risk  of  error,  as 
elsewhere  mentioned.  On  the  other  hand  radiography  and  fluoroscopy 
render  such  excellent  service  that  they  are  indispensable.  Consequently 
the  esophagosco]>ist  and  the  roentgenologist  both  must  labor  to  obtain  the 
best  results  for  the  patient.  The  best  illustration  of  this  is  the  fact  that 
while  the  esophagoscoi)e  can  give  all  the  certainty  of  actually  seeing  the 
spasmodic  closure  and  above  all  it  alone  can  inform  us  of  the  mucosal 
lesions:  yet  it  cannot,  as  can  fluoroscopy  and  radiography,  inform  us  of 
the  physiologic  functional  patho!og\-  during  the  act  of  deglutition. 

Etiology  of  spasm  of  the  esophagus.  It  is  easy  to  luidcrstand  why 
the  csophagtis  should  be  es[)ecially  prone  to  spasmodic  disease.  Its  en- 
tire functional  activity  is  dependent  upon  reflex  action.  Each  part  of  the 
gullet,  as  the  l)iiius  of  food  reaches  and  dilates  it,  is  stimulated  to  con- 
tract, thus  a  peristaltic  wa\e  moves  with  the  bolus  of  food  as  it  is  swal- 
lowed, and  while  it  is  undoubted  that  the  pneumogastric  nerves  are  con- 
cerned in  the  swallowing  act,  yet  it  is  nevertheless  true  that  the  action  is 
excited  reflexly,  because  only  the  very  start  of  the  swallowing  motion  is 
voluntary.  Once  the  start  is  made  by  the  constrictors,  the  balance  of  the 
movement  is  a  reflex  jieristalsis.  Swallowing  is  impossible  if  both  vagi 
arc  cut.  The  latter  experiment  would  contraindicate  the  possibility  of 
paralysis  or  paresis  being  in  some  instances  the  cause  of  what  is  known 
as  "cardiospasm,"  especially  as  the  division  of  these  nerves  causes  con- 
traction of  the  esophagus  in  the  neighborhood  of  the  cardiac  orifice,  as 
though  there  were  inhiliitory  fibers  supplied  only  to  the  region  of  the 
cardia.  The  auliior,  however,  esophagoscopically  has  deriionstrated  very 
clearly,  by  the  watching  of  a  few  cases  where  "cardiospasm,"  so  called, 
has  been  seen  early  but  for  various  reasons  has  remained  untreated,  that 
in  time  dilatation  has  gradually  followed.  The  etiology  of  the  condition 
has  thus  been  well  established  as  a  dilatation  due  to  pressure  above  the 
spasmodic  contraction  and  not  to  a  primary  atony  of  the  esophageal  wall. 

r^ranting  then  that)  spasmodic  stenosis  is  usually  a  reflex,  it  becomes 
interesting  to  study  the  sources  of  the  reflex.  I  lurried  gulping  of  food 
may  cause  spasm  and  thus  start  what  the  author  has  called  a  "vicious  cir- 
cle" as  will  be  hereafter  explained.  In  the  author's  experience  spasm  of 
the  esophagus  results  in  some  instances  from  lesions  tli.it  themselves  pro- 
duce no  sensation.  Thus,  sujierficial  erosions  may  excite  such  severe 
spasms  that  nothing  can  be  swallowed  and  yet  the  patient  have  no  sen- 
sation except  on  attempting  to  swallow,  and  even  then  the  only   sensa- 


506  DISEASES  OF  THE  ESOPHAGUS. 

tion  is  one  of  obstruction  not  of  pain.  Tliis  is  probably  to  be  explained 
by  the  fact  that  the  esophageal  pain  sense  is  less  efficient  than  the  eso- 
phageal tactile  sense.  For,  as  the  autlior  has  demonstrated,  the  esophagus 
is  quite  insensitive  below  the  cricoid  level.  Anyone  can  demonstrate  this 
insensitiveness  by  swallov^'ing  coffee  uncomfortably  hot.  No  sensation 
is  produced  after  the  hypopharynx  is  passed  until  the  stomach  is  reached 
and  in  the  stomach  the  sensation  is  so  slight  as  sometimes  not  to  be  noticed 
at  all.  Clinically,  we  know  that  esophageal  spasm  may  be  secondary 
to  local  diseases  of  the  esophagus,  or  to  disease  remote  from  the  guller. 
Thus  we  have  esophageal  spasm  as  a  result  of  li\er  disease,  probably 
supernuluced  in  some  instances  by  engorgement  of  the  veins  at  the  cardiac 
entl  of  the  eso[)hagus.  In  certain  cases,  there  are  undoubtedly  lesions  of 
the  mucosa  in  the  esophagus  and  also  in  the  stomach,  which  could  easily 
excite  spasms,  and  it  is  equally  certain  that  stagnation  due  to  the  spasm 
and  consequent  fermentation  of  food,  detention  of  secretions  and  macera- 
tion could  very  easily  e.xcite  or  perpetuate  the  lesions.  Thus  we  have 
a  "vicious  circle"  in  hiatal  and  abdominal  esophagismus.  Disease  of  the 
stomach  may  cause  severe  cases  of  spasmodic  stenosis  of  the  esophagus. 
The  author  has  seen  many  cases  in  which  cancer  not  itself  occluding  the 
cardia  has  produced  a  hiatal  esophagismus  that  had  nearly  starved  the 
patient.  In  other  cases  observed  by  the  author,  gastric  ulcer  has  produced 
the  same  condition.  Bassler,  by  post-mortem  examination  in  cases  of 
abdominal  esophagismus,  has  demonstrated  the  presence  of  visceral  dis- 
ease above  and  belovv  the  diaphragm. 

Spasms  of  the  cricopharj-ngeus  and  the  adjacent  circular  fibers  of 
the  esophagus  are  in  many  instances  secondary  to  chronic  gastric  disease. 
They  are  also  associated  with  rajjid  gulping  of  large  boluses  of  food.  The 
latter  may  be  a  factor  in  ])roducing  the  chronic  gastric  disorder :  but  it 
would  seem  that  it  mav  also  be  imlcpendently  causative.  The  presence 
of  s[)asm  in  cases  of  organic  stricture  has  been  seen  b\-  all  endoscopists, 
though  spasmodic  stenosis  is  rarelv  seen  in  a  much  infiltrated  area.  A 
case  of  spasmodic  stenosis  from  aphthous  ulceration  was  referred  to  under 
"Ulceration  of  the  esophagus." 

A  perpetuating  cause  in  established  cases  is  undoubtedly  the  "'nerve 
cell  habit,"  and  in  many  cases  the  presence  of  an  underlying  basic  neurotic 
factor  is  undoubted.  In  one  instance,  a  patient  who  was  c|uite  hysterical 
would  get  an  attack  of  abdominal  esophagismus  whenever  anything  did 
not  please  her.  For  instance,  she  took  the  notion  that  the  endoscopic 
di\ulsions  that  we  were  applying  to  the  abdominal  esophagus  were  tloing 
her  so  much  good  that  they  ought  lo  be  done  every  week  instead  of  every 
two  weeks.    Regularly  the  day  before  the  one  week  was  up,  her  abdominal 


DISEASES  OF  THE  ESOE'HAGUS.  507 

esophagus  would  shr.t  up  and  tliL-  dilatation  above  it  would  till.  L'.y  this 
it  is  not  meant  that  she  had  voluntary  control  of  it,  but  that  the  emotions 
sought  tiieir  outlet  through  habitual  nerve  channels,  producing  a  recur- 
rence of  the  abdominal  esophagismus,  which  she  had  had  since  childhood. 
This  "nerve  cell  habit"  is  one  of  the  most  frequent  causes  of  recurrences. 
In  the  author's  opinion  the  so-called  "cardio-spasm"  is  a  pathological 
prolongation  of  the  physiologic  hiatal  hesitation  in  normal  deglutition. 
Esophageal  spasmodic  stenosis  may  occur  at  any  age  Init.  in  the  author's 
experience,  it  is  rare  after  middle  life,  when  muscular  activity  is  on  the 
decline.  Spasm  of  the  esophagus  in  the  new-born  has  been  observed  once 
1)\-  the  autiior.     The  case  was  as  follows: 

Infant  Al.,  aged  two  days,  was  l)rought  to  the  author  by  Dr.  L.  C. 
Manchester  for  inability  to  swallow.  When  it  would  attempt  to  nurse 
the  lip  and  moutii  motion  were  correct  and  the  mouth  would  till  with  milk 
and  then  the  child  would  choke,  cough  and  strangle  and  the  milk  would 
all  run  out  of  the  mouth. 

These  symptoms  justified  a  suspicion  of  congenital  absence  of  more 
or  less  of  the  esophagus.  The  endoscope  was  gently  passed.  It  met  with 
moderate  resistance  at  the  cricopharyngeus  and  again  at  the  diaphragm 
but  the  lumen  of  the  esophagus  at  these  points  was  iierfectly  normal  and 
the  si)asmodic  constriction  gradually  yielded  to  the  gentle  insinuation  of 
the  esophagoscope.  Of  course  the  esophagoscopy  was  done  with(jut  anes- 
thesia. There  was  no  sign  of  the  slightest  trace  of  blood  on  the  instru- 
ment on  withdrawal,  and  best  of  all,  the  child  immediately  took  the 
breast  and  swallowed  perfectly.  Four  months  later  when  examined  by 
Dr.  Manchester  it  was  still  swallowing  perfectly. 

Remarks.  This  case  seems  to  have  been  a  si)asmodic  stenosis  of 
the  fundiform  fibers  of  the  inferior  constrictor,  and  of  the  diaphragm  at 
the  hiatus  esophageus.  The  author  has  been  unable  to  find  anv  similar 
case  in  literature,  and  feels  justified  in  regarding  it  as  a  case  of  esof^li- 
agisriiiis  in  the  iicic-horn.  The  prom])t  cure  by  eso])hagoscopv  we  see 
at  times  in  older  i)atients,  so  that  it  is  not  at  all  astonishing  that  the  i)as- 
sage  of  the  esophagoscope  should  cure  the  spasm  in  the  new-born  infant 
where  there  has  been  no  time  for  nerve  cell  habit  to  liecome  fixed.  .\n- 
other  interestins?-  feature  of  this  case  is  the  demonstration  of  the  harmless- 
ness  of  careful  esoi)hngoscopy  with  a  small  tube  (.■)  mm.)  in  a  new-born 
infant.  Cuisez  and  others  have  stated  that  esophagoscoi)\  cannot  be 
done  in  the  new-born.  \\  hilc  the  author  has  always  doubted  the  correct- 
ness of  that  statement,  no  opportunity  of  controverting  it  bv  actual  ex- 
perience arose  until  this  case,  though  esophagoscopv  in  a  number  of  in- 
fants  frcmi  two  til  twcKe  months  of  age  bad  led  me  to  belie\e  that   the 


508  DISEASES  OF  THE  ESOPHAGUS. 

procedure  could  be  done  without  anesthesia,  and  without  harm.  A  num- 
ber of  esophagoscopies  in  the  new-born  have  since  proven  equally  harm- 
less. 

In  addition  to  the  above-considered  secondarj^  manifestations  of 
spasm  dependent  upon  demonstrable  lesions  near  or  remote,  there  is  a 
small  number  of  cases  in  which  there  is  a  spasmodic  condition  which  we 
must  consider  primary,  and  which,  for  want  of  a  better  term,  must  be 
called  idiopathic,  objectionable  as  that  term  is,  until  a  definite  etiologic 
basis  has  been  discovered.  Doubtless  at  some  not  very  distant  day,  this 
class  of  cases  will  be  eliminated  by  the  results  of  the  present  wide-spread 
interest  in  esophageal  disease.  These  cases  are  doubtless  in  most  in- 
stances, functional  neuroses  yf  such  intricate  pathology  as  to  be  under- 
stood only  by  the  trained  neurologist. 

Globus  hystericus  is  the  name  given  to  the  sensation  described  by 
patients  as  a  "rising  of  a  lump  in  the  throat,"  or  some  such  expression.  In 
the  cases  with  this  sensation  esophagoscoped  by  the  author,  there  was  a 
contraction  of  the  cricopharyngeus  muscle.  The  reflex  impulse  may  be  a 
neurosis  of  similar  etiology  to  other  hysteric  phenomena;  but  quite  often 
it  is  e.xcited  reflexly  by  local  disease  in  some  part  of  the  esophagus,  and 
consequently  calls  for  esophagoscopy  in  most  instances.  It  seems  prob- 
able that  the  choking  sensations  of  grief,  and  after  weeping,  and  in  other 
emotional  phenomena,  are  due  to  the  same  spasmodic  condition  but,  of 
course,  being  purely  physiological,  they  do  not  call  for  esophagoscopy. 
The  following  case  illustrates  the  identity  of  "globus  hystericus"  and 
cricopharyngeal  spasm : 

A  man  of  'il  years  complaimrd  that  for  years  he  had  had  a  sensa- 
tion as  of  a  lump  rising  in  his  throat  at  various  times,  irrespective  of 
attempts  to  swallow.  Within  a  year  he  had  been  unable  to  swallow  any- 
thing after  twelve  o'clock,  noon  except  on  a  very  few  days.  In  the  fore- 
noon swallowing  was  rarely  interferetl  with.  The  author  observed  on 
one  occasion  the  patient's  attempt  at  swal'owing.  The  water  was  prompt- 
ly rejected,  coming  forcibly  out  of  the  mouth  and  nose,  accompanied  by 
cough  which  persisted  for  a  few  minutes.  A  sensation  of  a  lump  rising 
in  the  throat  was  complained  of  for  over  an  hour.  A  relative  stated 
that  the  patient  ate  ravenously  in  the  early  morning  and  at  about  eleven 
o'clock.  The  natient  was  well  nourished,  of  rather  stupid  expression, 
suggestive  of  the  atypical  child.  The  patient  mentioned  having  been 
examined  a  number  of  years  before  by  Dr.  Theodore  Diller,  the  neurol- 
ogist. The  author  obtained  from  Dr.  Diller  the  record  of  a  diagnosis 
of  hysteria  though  at  the  time  of  the  latter's  examination  there  was  no 
complaint   of   a   lump    in    the   throat   nor   of   anv    swallowing   symptom. 


DISEASKS  OF  TJIF.  KSOPIIAGUS.  501.' 

Examination  by  the  aulhor  rexealcd  a  typical  cricopharyngeal  spas- 
modic stenosis.  Swallowing  wa.-;  perfect  for  a  few  weeks  but  the 
diurnal  si)asmodic  stenosis  recurred,  and  with  it  came  the  sensation  of 
a  "lump  in  the  throat." 

The  author  has  seen  a  few  cases  somewhat  similar  to  the  fore- 
going but  none  of  them  has  been  cjuite  so  complete. 

That  the  early  manifestations  of  numerous  forms  of  organic  esoph- 
ageal disease  have  been  ignored  under  the  label  "globus  hystericus"  is 
now  unquestionable.  These  cases  may  or  may  not  be  associated  with 
dysphagia. 

Cricot^lnirynycal  spasmodic  stoiosis.  Most  cases  of  cricopharyngeal 
spasmodic  stenosis  are  unassociated  with  the  sensation  of  "a  lump  rising 
in  the  throat,"  known  as  "globus  hystericus,"  and  have  no  association 
with  hvsteria,  though  they  are  often  eironeously  thus  diagnosticated.  The 
disease  is  essentially  a  spasm  of  the  circular  fibers  of  the  inferior  pharyn- 
geal constrictor  known  as  the  cricopharyngeus  muscle.  The  symptomatic 
characteristic  of  this  affection  is  dil'liculty  in  swallowing,  which  consists 
in  a  dilticnlty  in  stiiitiii(i  the  food  downward.  (Jnce  the  food  is  started 
it  goes  downward  unimpeded  into  'he  stomach.  There  is  no  regurgitation 
of  food  sometime  after  swallowing,  unless  there  co-exists  in  the  same 
case  a  hiatal  esophagismus.  These  symptoms,  however,  denote  only  a 
high  esophageal  stenosis.  As  to  whether  it  is  a  s])asmodic  or  an  organic 
stenosis,  there  is  only  one  way  to  determine,  and  that  is  by  esophagoscopy 
It  may  even  be  both  organic  and  spasmodic,  the  latter  secondary  to  the 
former.  Local  malignant  disease  and  foreign  bodies  ma\-  also  give  rise 
to  spasmodic  stenosis. 

Esophiuioscopic  appearances  oj  sf'asiiiodic  stenosis  at  the  cricopharyn- 
geiis.  High  spasm  of  the  esophagus  unassociated  with  dixerticuhini,  may 
not  show  a  typical  form  as  disting'iished  from  the  spasm  that  always  oc- 
curs on  the  introduction  of  an  eso])hagoscope.  In  other  instances,  there 
will  be  a  slight  clamping  at  the  cricopharyngeal  le\el.  the  pictures  then 
being  of  a  small  point  of  lumen  from  which  radiate  slight  creases  or 
folds.  In  other  instances,  the  folds  are  not  so  ajjparent.  but  the  point 
is  in  the  center  of  an  almost  mammilliform  projection.  In  other  instances 
the  opening  in  the  |)rojection  will  be  slit-like  in  form  with  the  anterior 
and  posterior  lips  meeting  in  the  lenter  line,  the  slit  being  more  or  less 
transverse.  In  some  instances  there  is  a  curved  slit,  or  the  lips  may 
bulge  upw-ard  toward  thf  obser\er.  .\11  of  these  pictures  are  occasional- 
ly seen  in  the  normal  esophagus,  iluring  examination  without  anesthesia. 
Nevertheless  they  are  s])asm  j)ictures,  and  when  they  occur  in  the  normal 
esophagus,  they  indicate  simiilv  the  sjiasm  that  occurs  reflexl\-  from  the 


•">l(l  DISEASES  Ol-   THE  ESOPHAGUS. 

presence  of  tlie  tube.  AMien  we  encounter  a  patient  who  says  that  sud- 
denly while  eatit^g  he  will  choke  up  and  food  will  not  go  down,  and  upon 
esophagoscopy  we  tind  any  of  the  above  pictures,  and  especially  if  the 
spasmodic  picture  is  shown  in  connection  with  a  more  than  usually  un- 
yielding closure,  and  when,  furthermore,  the  spasm  gradually  yields  and 
the  esophagoscope  of  full  size  goes  through  readily  without  further  re- 
sistance, indicating  a  normal-sized  esophagus — under  such  circumstances 
we  are  justified  in  making  a  diagnosis  of  spasm  of  the  upper  end  of  the 
esophagus.  It  is  only  tlie  esophagoscopist  of  large  experience  who  can 
distinguish  between  a  n(irnial  degree  of  spasm  excited  by  the  tube 
in  a  normal  case,  when  the  tube  is  passed  without  an  anesthetic,  and  the 
case  in  which  there  is  a  pathologic  degree  of  spasm.  Furthermore,  it  is 
absolutely  necessary  to  be  certain  that  the  esophagoscope  is  properly 
pointed,  that  is,  that  its  axis  corresponds  precisely  with  the  axis  of  the 
lumen  of  the  esophagus,  and  that  it  is  not  impinging  more  upon  one  wall 
than  upon  the  other.  The  closed  lumen  may  open  uji  momentarily  when 
the  patient  gags  or  attempts  to  vomit,  or,  more  likely,  when  the  patient 
takes  a  deep  breath  after  a  continuous  strain  of  vomiturition.  Since 
there  is  always  more  or  less  spasmodic  obstruction  to  the  introduction  of 
the  tube  at  the  upper  end  of  the  esophagus,  the  beginner  will  find  great  dif- 
ficulty in  distinguishing  the  difference  between  a  normal  and  pathologic 
spasm,  and  even  the  most  experienced  will,  in  a  few  cases,  be  in  doubt. 

Treatment  of  spasmodic  stenosis  of  the  esophagus  at  the  crico- 
pharyngeal  leicl.  All  cases  associated  with  a  morbid  source  of  reflexes, 
near  or  remote,  should  be  cured  of  the  basic  lesion.  A  few  of  such  cases 
and  all  of  the  purely  functional  cases  can  be  cured  by  the  passage  of  a 
large  esophagoscope.  Recurrences  may  reeiuire  similar  treatment  at 
intervals  for  a  year  or  two,  but  many  cases  are  cured  by  a  single  treat- 
ment. 

Hiato!  csopha(/isiniis  (so-called  "cardiospasm").*  L'ndoubtedly  the 
old  word  "cardiospasm,"  like  many  of  the  oUl  words  of  medicine,  cov- 
ered a  number  of  different  conditions  of  independent  etiology  and  pathol- 
ogy. The  word  cardia  is  ])roperly  used  as  the  name  of  the  esophageal 
orifice  of  the  stomach.  Spasm  limited  solely  to  this  orifice,  is  certainly 
exceedingly  rare,  while  spasm  of  the  abdominal  esophagus  and  of  the 
esophagus  at  the  hiatus,  either  separately  or  together,  are  relatively  com- 
mon, and  should  be  called  by  their  proper  names.  The  word  "cardio- 
spasm" should  either  l)e  dropped  as  a  misnomer  or  limited  to  those  rare 
cases  of  true  cardial  esophagismus.     Brown  Kelley  has  demonstrated  the 

•Liberal  quotations  are  made  in  the  following  pages  from  the  author's  "Kap- 
port"  to  the  International  Medical  Congress,  Section  XV,  London,  1913. 


DISKASES  OK  TlIK  KSOPIIAGUS.  511 

experimental  fact  that  section  ai  ijoth  vagi,  without  stimulation,  is 
followed  by  dilatation  of  the  lower  part  of  the  esophagus  and  contractioi: 
of  the  cardia.  which  he  rightly  says  corresponds  to  the  supposed  condi- 
tion in  cariliospasm.  I'.ut  as  a  clinical  morbid  entity,  such  a  condition 
is  rarel}',  if  ever,  found  in  the  disease  commonly  known  as  cardiospasm. 

The  author's  contention  in  his  earlier  book  (  I5ib.  2(i!l,  p.  271  )  that 
the  so-called  "cardiospasm"  was  in  reality,  in  almost  ail  instances,  more 
properly  a  hiatal  esophagismus  or  phrenospasm,  was  based  purely  upon 
endoscoi)ic  clinical  observation.  Recently,  however,  in  a  very  interesting 
monograijh.  Liebault  (  Bib.  ;?2!l )  has  furnished  the  anatomical  basis  for 
the  obser\ation.  I'Voni  careful  dissection  he  has  found  the  muscular 
fibers  which  are  so  active  in  a  sphincteric  action  of  the  esophagus  at  the 
hiatal  level,  as  shown  in  the  drawing  Fig.  41<i.  (Jn  investigation,  he 
fovmd  that  Rouget  had  described  the  local  anatomy  in  essentially  the  same 
way.     He  quotes  Kouget's  description  as  follows : 

"The  muscular  fibers  of  the  sphincter,  slightly  paler  than  the  rest  of 
the  muscle,  slender  and  not  numerous,  leave  each  crus  at  the  level  of  the 
hiatus  and  pass  to  the  esophagus,  with  wdnose  fibers  they  are  interlaced 
terminating  by  the  formation,  on  the  anterior  aspect,  of  loops  interlacing 
with  those  of  the  opposite  side.  The  small  muscular  bundles,  more  or 
less  developed  but  constant,  ordinarily  exist  only  on  the  sub-diaphrag- 
matic portion  of  the  esophagus.  In  one  instance,  I  found  a  thin  muscular 
lamina  1  cm.  in  size  which  extended  from  tl.e  left  crus  to  the  cardia,  end- 
ing by  spreading  its  fibers  over  the  anterior  wall  of  the  stomach.  I  have 
almost  always  found  the  esophagus  and  cardia  united  at  the  external 
border  of  the  left  crus  by  a  lamina  of  fibrillar  ajiiJcarance  but  endowed 
with  special  elasticity  such  as  characterizes  the  dartos,  and  which  is 
found  also  at  the  level  of  the  terminal  loops  of  the  cremaster  in  the  adult." 
Liebault  adds,  "Classically,  the  hiatus  is  described  as  of  elli])tic  form 
and  such,  indeed,  it  appears  to  be  on  inspection  from  above,  but  on  ex- 
amination of  its  abdominal  aspect  it  appears  rather  that  the  esophagus 
has  insinuated  itself  between  the  diaphragmatic  libers,  which  it  has 
spread  apart  in  order  that  it  mav  enter  the  abdominal  cavitv.  It  is  not 
an  elliptic  orifice,  but  rather  a  cleft  througli  which  the  esuphagus  passes. 
I.iebault  agrees  with  others  who  havt  been  unable  to  demonstrate  any 
increase  in  the  circular  fibers  at  the  true  cardia  as  com])ared  with  the 
circular  libers  of  other  [xntions  of  the  esophagus. 

In  further  confirmation  of  the  author's  contention  (  llib.  2i)!)  )  against 
the  misleading  word  "cardiospasm,"  anatomic  study,  in  addition  to  the 
demonstration  by  Liebault  above  <|uoted,  has  also  demonstrated  the  al)- 
sence  f)f  anything  th;it  could  be  c;dled  a  sphincter  at  the  cardia.  and  the 


512 


DISUASKS  OF  THE  ICSOPHAGUS. 


narrowing  at  this  ])oint  that  has  been  shown  in  so  many  text  books  on 
anatomy  is  a  misfortune.  Hill  quotes  McAllister  to  tlie  effect  that  there 
is  no  histologically  demonstrable  siihincter  and  he  states  that  the  circular 
musculature  at  this  point  is  weak.     Brown  Kellv  and  \\'illiamina  .\ble, 


Fig.  410. — Drawing  of  the  under  surface  of  the  diaphragm  showing  the  con- 
stricting musculature  at   the  liiatus.      (After  Liebault). 


by  careful  special  dissections,  ha\e  demonstrated  that  "it  is  quite  ap- 
parent to  the  naked  eye  that  both  muscular  coats  are  of  uniform  thickness. 
and  that  no  special  aggregation  of  fibers  exists  at  or  near  the  cardia,"  and 
that  "nothing  was  found  in  any  of  the  dissections  or  in  the  anatomical 


DISEASES  OF  THE  ESOPHAGUS.  513 

works  consullctl   tu  justify    Dr.   Hill's  statcnicm  thai  ihc  circular  fiber 
musculature  was  specially  weak  ui  this  region." 

IVrsoually,  the  author  believes  that  it  is  only  very  rarely,  if  ever, 
that  any  spasm  exists  below  the  hiatal  level,  but  in  order  to  place  the 
study  on  a  systematic  basis,  he  believes  that,  as  endoscopists,  it  would  be 
better  for  us  to  abandon  the  word  "cardiospasm"  and  to  substitute  for  it 
the  three  clinical  types,  that  may  possibly  be  made  out :  namely, 

1.  Hiatal  esophagismus. 

2.  Abdominal  esophagismus. 
•3.     Cardial  esophagismus. 

That  the  constriction  in  so-called  "cardiospasm"  is  first  encountered 
at  the  hiatus  no  one  who  knows  the  hiatal  esophagus  when  he  sees  it 
can  deny.  And  no  experienced  observer  can  deny  that  after  the  tube- 
mouth  has  passed  the  hiatal  constriction  it  goes  through  the  two  to  four 
centimeters  of  abdominal  esophagus  into  the  stomach  with  Init  little 
resistance,  which  lessens  as  the  stomach  is  approached.  The  degree  of  the 
resistance  of  this  abdominal  esophagus  varies.  In  most  cases  the  author 
has  fell  inclined  to  regard  it  as  so  slight  that  he  would  dismiss  it  as  a 
factor  in  spasmodic  stenosis  if  it  were  not  for  two  things:  1.  The  pos- 
sibility of  its  relaxation  simultaneously  with  the  hiatal  yielding;  and,  (2) 
the  radiographic  studies.  With  the  question  in  mind  he  has  watched  the 
yielding  of  the  abdominal  esophagus  as  the  hiatus  is  passed  and  he  feels 
inclined  to  say  that  abdominal  esophagismus  does  not  exist  except  in 
conjunction  with  hiatal  eso])hagismus.  Further,  if  cardial  esophagismus 
exists,  (the  author  has  obserxed  only  three  cases  which  he  would  feel 
justified  in  classing  as  such)  it  does  not  exist  except  in  conjunction  with 
hi;ital  esophagismus,  or  as  the  author  first  called  it,  phrenospasm.  A 
study  of  the  ra(liograi)hs  such  as  Figs.  -Ill  and  413,  reveals  the  possibil- 
ity of  two  interpretations.  The  narrow  streak  of  bismuth  shadow  be- 
low the  very  evident  hiatal  constriction  might  indicate  either  a  spas- 
modically contracted  lumen  of  Mie  whole  abdominal  esophagus,  or  a 
trickling  stream  of  leakage  that  was  escaping  through  the  almost  tightly 
shut  hiatus  above.  As  a  matter  of  fact  we  know  that  the  food  in  these 
cases  of  spasmodic  stenosis  does  leak  through  gradually,  rarel>.  if  e\er, 
suddenly.  l'"urtlier  in\  estig.'itiiiu  nf  this  point  is  needed.  l'"rom  esophago- 
scopic  observations,  the  author  knows  that  the  hiatal  esophagus  is  ligiilly 
contracted  in  the  disease  known  as  "cartliospasm." 

Hiatal  esophagismus,  even  more  than  di\  ertieulum,  reminds  one  nf 
the  ingluvies  of  birds,  inasmuch  as  the  dilated  esophagus  fills  (|uickly, 
and  yet  there  is  a  constant  leakage,  which  allows  a  certain  proportion 
of  the  food  to  pass  on  through  at  a  relatively  slow  rate.     In  one  of  the 


514  DISKASKS  OF  THIC  ESOPHAGUS. 

author's  patients,  the  cure  of  the  abdominal  esophagismus  by  divulsion, 
resulted  in  food  going  through  so  promptly  into  the  stomach,  that  taking 
food  excited  nausea  lor  quite  a  long  time  until  the  stomach  became  ac- 


FiG.  411. — Radiograph  ol  a  woman  of  45,  shoiNiiij;  an  abdominal  isoiihagismus 
vvliich  was  afterward  cured  by  endoscopic  mechanical  divulsion.  The  "flat  floor"  of 
the  dilatation  shows  why  previously  used  blind  methods  had  failed  to  introduce 
any  instrument  through  the  hiatus. 

customed  to  the  unusual  sensation  of  having  food  go  through  directly 
when  swallowed.  Patients  afflicted  with  spasm  of  the  abdominal  esoph- 
agus usually  complain  of  distress  after  eating  and  regurgitation  of  food 
within  a  period  of  from  a  c|uarter  of  an  hour  to  several  hours  after  eat- 


DISEASES  OE  THE  ESOPHAGUS. 


51  o 


iiig.  At  limes,  especially  if  ihe  sac  be  large,  there  will  be  no  regurgitation 
for  a  number  of  days,  when  a  large  quantity  of  stale  food  may  come  up. 
In  many  instances,  hiowever,  but  a  very  small  quantity  of  food  is  re- 
gurgitated, though  the  accumulation  be  large.     It  will  pass  gradually,  a 


Fu;.  41J, — Ka(li(i};ra])Ii  (jf  a  woman  of  2.S,  sliowinn  an  abiluminal  esnpliaHismus 
with  only  very  slight  dilatation  above  it.  The  deviation  of  the  esophagus  by  the 
aorta  was  verified  csophagoscopically  (Author's  case.  Radioyrapli  made  by  Hr. 
J.  C,  Bowen), 


little  at  a  time,  as  the  spasm  relaxes,  into  the  stomach  and  usually  (though 
not  always)  before  a  serious  state  of  inanition  supervenes.  The  symp- 
toms are  not  meant  as  in  any  way  diagnostic.     There  are  no  absolutely 


516  DISEASES  OF  THE  ESOPHAGUS. 

diagnostic  signs  of  esophageal  disease,  and  the  author  in  tlie  present 
work  has  referred  but  little  to  them.  The  fact  of  the  matter  is  that  any 
patient  coming  in  with  any  symptoms  whatever  that  could  be  possibly 
referable  to  the  esophagus,  requires  an  esophagoscopy.  Any  sort  of  diag- 
nosis based  upon  signs  and  symptoms  is  so  apt  to  be  erroneous,  that  it  is 
not  worth  while  to  more  than  make  a  decision  that  the  symptoms  justify 


Fig.  413. — Radiograph  of  a  woman  twenty-two  years  of  age,  affected  with 
hiatal  esophagismus  simidating  diverticulum.  The  shadow  of  the  bismuth  porridge 
rests  upon  about  i^  liters  of  stale  food  in  an  enormous  dilatation  as  demonstrated 
esophagoscopicilly   after   emptying.      (Author's   case). 

esophagoscopy.  For  instance,  all  the  signs  of  cancer  of  the  esophagus 
may  be  present  and  yet  the  esophagoscope  will  show  nothing  more  than 
spasm  of  the  hiatal  esophagus.  The  exact  reverse  may  be  true  and  the 
patient  may  have  all  the  symptoms  of  abdominal  esophagismus  for  many, 
many  years,  and  yet  esophagoscopy  may  show  an  incipient  or  even  well- 
developed  cancer  which  has  arisen  u])on  the  site  of  some  inflammatory 
area  within  the  esophagus. 


nisKASKs  01"  Tine  i^sopiiagus. 


517 


The  diagnosis  of  hiatal  csoj^ha^/isinus  is  easy  in  the  t\pical  case  witli 
an  enormons  dilatation,  a  white,  pasty,  macerated  mucosa,  and  a  con- 
tracted esophagus  which,  however,  permits  a  large  esophagoscope  to  pass 
into  the  stomach  after  a  delay  at  the  hiatus;  hut  in  the  early,  or  in  the 
less  typical  cases,  without  dilatation  it  is  often  exceedingly  ilitilcult  to  dis- 
tinguish between  purely  spasmodic  conditions  and  those  of  local  lesions 
in  the  neighborhood  of  the  esophagus  but  not  themselves  showing  in 
compressions  or  very  marked  deviations  of  the  abdominal  esophagus.  Tn 
such  cases,  while  many  esophagoscopists  feel  sure  of  their  diagnosis,  many 


Fig.  414. — Lateral  radiograph  of  same  patient  as  in  Fi.n.  41.?,  the  shadow  of 
liie  bismuth  mixture  simulating  diverticuUim.  The  mass  of  food  after  eating 
protruded  in  the  neck  and  could  be  evacuated  by  external  pressure  with  the  pa- 
tient's hand. 


do  not  agree  as  to  what  the  endoscopic  pictures  are,  and  many  endos- 
copists describe  a  i)icture  which  is  seen  by  other  endoscopists  in  the  per- 
fectly normal  esophagus  abdoniinalis.  It  is  in  such  cases  that  the  bis- 
muth radiograjih,  useful  in  anv  case,  is  of  especial  value.  The  best  of  all 
methods,  however,  is  by  the  trained  sense  of  touch  which  by  long  experi- 
ence c|uickly  detects  more  than  normal  resistance  at  the  hiatus.  This 
must  be  determined,  and  the  experience  must  be  acquired  by  esophagos- 
copy  without  general  anesthesia  because  in  deep  anesthesia  there  is  no 
resistance,  and  partial  anesthesia  introduces  a  variable  element.     Local 


518 


DISKASKS  01'  THK  ESOPHAGUS. 


Fig.  415. — Radiograph  of  a  woman  of  thirty-eight  years.  The  shadow,  which 
so  much  resembles  a  diverticulum,  was  esophagoscopically  proven  to  be  a  dilata- 
tion above  a  stricture  of  probably  luetic  origin.  The  stricture  is  behind  and  above 
the  bottom  of  the  lower  border  of  the  shadow  of  tlie  dilatation.  Endoscopic  dilata- 
tion resulted  in  a  cure,  after  which  a  bismuth  mixture  went  through  into  the 
stomach  so  promptly  as  not  to  show  in  a  radiograph.  Fluoroscopic  examination 
showed  swallowing  to  be  normal.  (Radiograph  by  Dr.  Russell  H.  Boggs.)  The 
lower  illustration  shows  the  endoscopic  appearance  of  the  suprastrictural  dilatation. 
The  orifice  of  the  stricture  is  hidden  by  tlie  overhanging,  whitish,  cicatricial   fold. 


DISEASES  CI-   THE  ESOPHAGUS.  519 

anesthesia  has  Init  little  and  a  very  uncLitiin  influence  on  relaxation  of 
spasm.  Radiography  may  lead  to  error  as  in  the  case  illustrated  in  Fig. 
41;^,  41J,  and  ll."). 

The  possibility  of  the  radiograph  being  taken  just  before  normal 
physiologic  opening  of  the  abdominal  esophagus  in  the  deglutitory  cycle 
must  be  borne  in  mind  in  the  interpretation  of  radiographs.  It  is  to 
be  eliminated  in  each  case  by  the  comparison  of  a  number  of  plates,  and 
by  the  elapsed  time. 

Treatment  cf  hiatal  esophagismus  {so-called  "cardiospas>n").  Treat- 
ment of  abdominal  esophagismus  and  hiatal  esophagismus,  has  led  to 
the  devising  of  a  number  of  difl:"erent  water-bags  and  air-bags,  which 
have  \ielded  good  results.  In  some  cases,  however,  it  is  impossible  to 
introduce  them.  The  author's  personal  preference,  like  that  of  Briinings', 
is  for  a  mechanical  divulsor  inserted  through  the  esophagoscope  where 
the  sense  of  touch  and  the  precision  of  a  steel  instrument  give  one  an 
accurate  control.  Heavy,  spring-opjiosed  handles  are  a  mistake  as  they 
prevent  the  safeguarding  of  the  divulsion  by  the  delicate  sense  of  touch. 
The  autlior  uses  the  di\iilsor  that  Moshcr  devised  for  the  rapid  dilatation 
of  cicatricial  strictures,  Fig.  IS.  The  method  is  simple.  The  53  cm. 
esophagoscope  is  passed  into  the  stomach  until  it  reaches  the  greater 
curvature.  Then  the  divulsor.  closed,  is  passed  through  the  esophago- 
scoj-e  until  the  distal  enc'  of  the  divulsor  touches  the  greater  curvature  of 
the  stomach.  Then  the  esojjhagoscope  i,s  withdrawn  until  the  slightly  ex- 
panded expansile  portion  of  the  di\-ulsor  is  endoscoi)ically  seen  to  be  all 
exposed  beyond  the  Inbe-mniuli.  I  he  partial  withdrawal  of  the  eso[)h- 
agoscope  is  done  under  the  guidance  of  the  eye  so  that  the  largest  diam- 
eter of  the  divulsor  can  be  seen  to  be  in  the  hiatal  esophagus.  It  is  then 
expanded  to  the  lull  |iliysiological  size,  about  ?il  to  'i')  millimeters  in  the 
adult,  unless  resistance  to  expansion  is  felt,  (".reat  care  is  necessary  not 
to  use  undue  force  which  might  ru])ture  the  esophagus ;  but  the  trained 
touch  will  do  no  hartn.  The  dilaioi'.  tully  expanded  in  the  living  patient, 
is  shown  in  the  radiograph,  ]'\g.  I  ji,.  Tbe  divulsor  is  allowed  to  remain 
in  its  expanded  position  for  from  live  to  ten  minutes.  It  is  then  con- 
tracted with  the  screw  mechanism,  great  care  being  used  to  avoid  pinch- 
ing the  mucosa  as  the  blades  close.  If  there  is  any  teudeucy  to  this,  the 
blades  should  be  re-e\panded  slightly  and  the  divulsor  rotated  gently.  Di- 
vulsion is  somewhat  painful  and  the  use  of  ether  anesthesia  is  a<lvisable, 
not  onlv  for  this  reason,  but  especially  to  prevent  xomiting  while  the  di- 
vulsor is  fi'.lly  expanded  winch  mi.trht  cause  tr;uim;i.  I'Vom  one  to  six 
divulsions  at  intervals  of  a  week  are  necessary. 


520 


DISEASES  OF  THE  ESOPHAGUS. 


It  is  necessary  after  any  form  of  treatment  to  instruct  the  patient 
to  eat  very  slowly  and  to  masticate  very  thoroughly.  It  is  altogether 
probable  that  very  rapid  eating  and  insufficient  mastication  may,  in  some 
instances,  be  one  of  the  factors  contributing  to  the  cause  of  spasm  of  the 
esophagus,  because  we  know  that  in  certain  instances  small  foreign  bodies 
will  cause  a  spasm,  as  evidenced  by  complete  obstruction  of  the  esoph- 
agus by  a  foreign  body  too  small  to  block  up  the  canal.     Liquid  foods 


Fig.  416. — Divulser   fully  expanded    (24  mm.)   in  the  living  patient,  a  man  01 
twenty-one  years.     The  double  image  is  due  to   respiratory  movement. 


taken  in  very  small  (|uantitifs  frequently  repeated  are  best  during  the 
treatments  and  for  a  month  or  longer  thereafter  in  order  to  permit  reso- 
lution of  the  macerated,  inflamed  esophagus.  L'ndoubtedly  there  are  a 
few  cases  that  are  prone  to  recur,  and  the  most  stubborn  are  those  ex- 
isting since  childhood,  with  consequent  infantile  stomach  and  long-estab- 
lished "nerve  cell  habit."  The  neurologist  should  be  called  in  consultation 
in  cases  that  do  not  yield  promptly  to  divulsion. 


DISEASES  OF  TIIK  ESOPHAGUS.  521 

The  foregoing  is  the  method  that  has  yielded  the  author  the  best 
resuhs.  There  are  a  number  of  otlicr  methods  successfully  used  by  Plum- 
mer,  Jesse  Meyer,  Lerche  and  others,  ?.nd  their  writings,  reference  to 
which  will  be  found  in  the  Bibliography,  should  be  consulted. 

Dilating  bags  filled  with  air  or  water  after  insertion  on  the  prin- 
ciple of  Horrock's  maieutic  are  e*Tfective  if  accurately  placed.  It  is  so 
difficult,  however,  to  place  them  accurately  by  blind  methods,  that  esoph- 
agoscopic  placing  seems  preferable  to  the  author,  who,  however,  may 
be  biased.  Gastrostomy  through  the  abdominal  wall  with  retrograde 
dilatation  of  the  cardia  has  been  done  quite  a  number  of  times,  but  in 
view  of  the  beautiful  results  that  are  obtainable  endoscopically,  such  pro- 
cedure seems  unjustifiable,  until  endoscopic  methods  have  utterly  failed 
to  cure.  It  is  difficult  to  see  how  any  more  thorough  stretching  can  be 
done  from  below  than  could  be  done  from  above.  Gastrostomy  for  feed- 
ing is,  usually,  contraindicated  because  a  stomach  tube  can  be  placed  with 
the  esophagoscope,  if  a  case  is  encountered  where  the  spasm  is  so  severe 
or  the  superjacent  diffuse  dilatation  is  so  great  that  the  stomach  tube 
cannot  be  passed  otherwise.  The  author  has  seen  a  number  of  cases 
where  the  stomach  tube  could  not  be  passed  because  the  patient  could 
not  aid  by  swallowing  efiforts,  and  the  stomach  tube  would  strike  the  flat 
floor  (See  Fig.  411)  of  the  dilatation  and  had  no  tendency  to  enter  the 
hiatal  esophagus.  In  all  such  cases  the  author  has  found  it  exceedingly 
easy  to  introduce  the  gastroscope  and  through  it  to  pass  a  soft  rubber 
stomach  tube  for  feeding.  The  gastroscope  was  withdrawn,  leaving  the 
feeding  tube  in  situ.  In  case  an  endoscopist  is  not  available,  gastrostomy 
for  feeding  is,  of  cotirse,  advisable  before  the  patient's  nutrition  has  suf- 
fered too  much.  Duodenal  feeding  through  the  duodenal  feeding  tube 
has  been  used  with  excellent  results  by  Clement  R.  Jones,  T.  W'ray  Gray- 
son and  others. 


CHAPTER  XXXII. 

Diseases  of  the  Esophagus.-  Continued. 

CICATRICIAI.   STEXOSIS   OF    THF,    ESOPHAGUS. 

Etiology*  The  most  common  cause  of  cicatricial  stenosis  is  the 
swallowing  of  corrosive  poisons,  especially  caustic  alkalies.  It  is  a  pitiable 
thing  to  see  little  children  threatened  with  starvation  because  of  a  cica- 
tricial esophageal  stenosis  due  to  the  swallowing  of  some  form  of  caustic 
alkali  to  which  the  laxity  of  our  laws  permitted  them  to  be  exposed.  The 
law  requires  that  the  druggist  shall  label  corrosive  poisons  "Poison"  and 
the  careful  druggist  adds  antidotal  advice.  Next  door  to  the  druggist, 
the  grocer  sells  corrosive  poisons  having  on  the  label  no  hint  of  caution, 
but  having  directly  misleading  statements,  such  as  "Will  not  hurt  the 
hands,"  "Will  not  harm  the  most  delicate  fabric,"  etc.  It  is  the  general 
impression  that  concentrated  lye  is  a  relic  of  the  old  days  of  home-made 
soaps,  but  investigation  shows  that  it  is  in  common  use  in  the  household 
for  labor-saving  cleansing  of  all  kinds.  Its  harmful  effect  on  the  hands 
conveys  to  the  thoughtful  some  hint  of  the  caustic  nature  of  its  con- 
tents. But  the  frequency  with  which  patients  with  esophageal  stricture, 
following  the  swallowing  of  concentrated  lye.  come  in  an  almost  fatal 
state  of  inanition  to  the  esophagoscoinst,  is  an  index  to  the  thoughtless- 
ness of  the  users  of  concentrated  lye.  and  an  urgent  call  for  legislation 
that  shall  compel  the  manufacturer  to  label  concentrated  lye  containers 
"Poison"  and  to  state  a  few  antidotes,  even  if  this  does  diminish  slightly 
the  sale  of  such  products.  Esophageal  stricture  from  the  swallowing 
of  commercial  lye  has  been  for  many  years  a  lesion  of  common  observa- 
tion by  those  interested  in  the  esophagus.  The  frequency  declined  with 
the  more  general  substitution  of  cheap  commercial  soaps  for  the  home- 
made products ;  but  concentrated  lye  is  stil!  in  extensive  use  for  general 

*Part  of  this  section  on  etiology  is  revised,  with  .additions,  from  the  author's 
'Chairman's  Address"  to  the  Section  on  Lar.vnprologry  of  the  American  Medical 
Association.   1910.      (Bib.   241.) 


IMSKASES  OF  TIIK  I-SOI'Il AGIJS.  523 

scrubbing  ami  cleansing  purposes.  Furthermore,  strictures  of  the  esoph- 
agus are  again  on  the  increase  owing  to  the  flooding  of  the  market  with 
a  large  number  of  proprietary  "cleansers"  for  household  use  and  "wash- 
ing powders"  for  laundry  use.  The  author  has  seen  three  cases  of  the 
most  severe  ulceration  and  sloughing  of  the  esophagus  from  the  swallow- 
ing of  strong  solutions  of  three  of  these  proprietary  preparations.  The 
author  has  had  the  preparations  analyzed  and  all  contained  similar  in- 
gredients :  an  abrasive,  a  strong  powdered  soap,  and  a  caustic  alkali : 
namely,  soda  ash.  The  proportions  varied  from  eight  per  cent  in  the 
"cleansers"  up  to  forty  or  fifty  per  cent  in  the  laundry  powders;  but  in 
none  was  the  corrosive  alkali  so  diluted  as  not  to  be  caustic  to  the  deli- 
cate esophageal  mucosa  of  a  child.  And,  worst  of  all,  the  mixture  was 
not  thorough ;  therefore  some  portions  were  more  concentrated  than 
others,  so  that  under  certain  conditions  it  would  be  possible  for  a  child 
to  get  a  concentrated  dose  of  caustic.  Another  thing  which  doubtless 
contributes  to  the  danger  is  the  insoluble  nature  of  the  abrasive  and  the 
slower  solubility  of  the  soap.  Thus,  a  litde  water  dissolves  out  the  al- 
kali in  strong  solution.  The  accident  in  a  number  of  cases  occurred 
thrtjugh  the  child's  swallowing  the  ringings  of  the  almost  empty  can.  The 
economical  mother  was  endeavoring  to  extract  the  dregs  for  use  ;  and, 
totally  unsuspicious  of  a  i)rcparation  wliicb.  could  not  "injure  the  most 
delicate  fabric,"  did  not  place  the  can  oat  of  reach  of  the  child.  In  an- 
other instance  the  cleansing  powder  had  been  sprinkled  on  the  dishes  in 
the  dish-pan.  From  one  cup  it  was  not  removed  by  rinsing,  the  powdered 
soap  in  its  composition  making  it  adherent,  and  from  this  cup  the  child 
drank.  In  the  third  instance  the  child  drew  water  from  a  faucet  into  a 
cup  that  had  been  used  to  measure  out  a  quantity  of  a  proprietary  wash- 
ing powder  for  laundry  use.  On  not  one  of  the  containers  of  these  three 
widely  advertised  proprietary  caustic  prei)arations  was  there  one  hint 
of  the  dangerous  nature  of  the  contents.  .Vmmonia,  "salts  of  tartar" 
(potassium  carbonate),  mercuric  bichloride,  strong  acids,  etc..  are  less 
frequent  causes  of  cicatricial  stenoses.  It  was  at  one  time  supposed  that 
cicatricial  stenosis  of  the  esophagus  was  invariably  due  to  the  swallow- 
ing of  corrosives.  It  is  <|uite  well  established  now,  that  tuberculosis,  lues, 
scarlatina,  diphtheria  and  various  pyogenic  conditions  can  j^roduce  ul- 
ceration followed  by  cicatricies  in  the  esophagus.  MacReynolds  reports 
the  discovery  at  autopsy  of  a  large  area  of  ulceration  in  the  esoj^hagus  of 
a  patient  who  died  of  spontaneous  rupture  of  the  esophagus,  complicating 
mastoid  disease.  Chronic  esophagitis  from  spasm  with  stagnation  of 
food  and  secretions,  as  seen  in  abdominal  and  hiatal  esophagismus,  (er- 
roneously called  "cardiospasm"  I  may  result  in  superficial  erosions  which 


524  DISEASES  OF  THE  ESOPHAGUS. 

when  the  pyogenic  infections  become  engrafted  upon  them,  may  result 
in  serious  cicatrices.     Thus  we  have  an  organic  stenosis  following  upon 
a  spasmodic  stenosis.     Every  esophagoscopist    of    large    experience    has 
seen  cases  of  cicatricial  stenosis  of  the  esophagus  in  which  he  is  utterly 
at  loss  to  discover  the  original  caiise  of  an  undoubted  cicatricial  stenosis. 
The  so-called  "peptic"  ulcer  of  the  lower  portion  of  the  esophagus  may 
be  a  cause.     Observations  by  Guisez,  MacKinnie  and  also  some  observa- 
tions of  the  author  point  clearly  to  the  fact  that  spasmodic  lesions  can 
produce  organic  stricture  by  the  erosions  due  to  the  accompanying  esoph- 
agitis.    Decubitus  ulcer  of  typhoid  fever    has  caused  cicatricial  esophageal 
stenosis.     The  author  has  previously  pointed  out  the  occurrence  of  an 
ulcer  in  the  esophagus  from  sphacelus  of  the  esophageal  mucosa  in  the 
low  ^•itality  of  profound  typhoid  toxemia.     Since  that  time  five  cases  of 
post-typhoid  stenosis  from  cicatricial  contraction  have  been  sent  to  the 
author.     In  four  of  these  cases  the  cicatrix  was  at  the  cricoid  level,  evi- 
dently due  to  the  pressure  of  the  cricoid  against  the  vertebral  column, 
pinching    the    esophageal   wall,    the    vitality     of     which     was     lowered 
by  the  typhoid  toxemia,  ending  in  sloughing  and  ulceration.     In  the  other 
case  the  cicatrix  was  at  the  level  of  the  crossing  of  the  left  bronchus. 
Whatever  be  the  nature  of  the  original  lesion  the  stenotic  cicatrix  is  usual- 
ly  the   result  of  the   inflammatory   infiltration   resulting   from  the   pro- 
longed ulcerative  processes  due  to  the    secondary    mixed    pyogenic    in- 
fections.    Any  sort  of  stenosis  of  riie  esophagus,  if  long  continued,  may, 
by  the  stagnation  of  food  and  secretion,  set  up  esophagitis  and  ulceration 
resulting   in   cicatrices.      In   view   of   this,    slight   degrees   of   congenital 
stenosis  may  be  considered,  possibly,  a  contributing  cause.     As  pointed 
out  by  Brown  Kelly   (Bib.  303)   slighter  degrees  of  organic  stenosis,  in 
some   instances   possibly  congenital,   may   have   existed    for    years    un- 
noticed by  the  patient.     Cicatricial  stricture  of  the  esophagus  may   fol- 
low prolonged  sojourn  of  a  foreign  body.     The  presence  of  a   foreign 
body  results  in  a  localized  ulceration  with  hy]:)erplasia.     During  a  pro- 
longed period,  this  round-celled  infiltration  increases  and  later,  after  the 
foreign  body  is  removed,  the  contraction  of  the  cicatricial  tissue  results 
in  a  greater  or  less  stenosis  of  the  esophageal  lumen.     In  one  case  of 
this  kind,  seen  by  the  author,  in  a  child  four  years  of  age,  a  coin  had  been 
removed  by  a  general  surgeon  by  external  esophagotomv  after  the  coin 
had  been  in  situ  for  nearly  one  year.     After  the  wound  had  healed,  the 
child  could  swallow  quite  well,  but  in  a  few  weeks  difficulty  in  swallow- 
ing began  to  appear,  becoming  gradually  worse  until  at  the  end  of  two 
months  a  very  severe  degree  of  stenosis  was  present,  permitting  only 
liquids  to  pass.    The  author  cured  the  stricture  by  forcible  dilatation  and 


DISEASES  OF  THE  ESOPHAGUS.  525 

continued  bouginage  f^er  tubain.  It  seemed  to  be  very  mucb  more  amen- 
able to  treatment  than  the  stricture  cases  following  the  swallowing  of 
lye,  and  the  stricture  was  only  single,  while  those  following  the  swallow- 
ing of  caustic  alkalies  are  usually  multii^le,  the  openings  not  being  con- 
centric. 

Site  of  cicatricial  stricture  of  the  esophagus.  The  author's  experi- 
ence has  been  quite  at  variance  wi'.h  that  of  Guisez.  The  latter  reports 
that  out  of  38  cases  due  to  corrosives  the  site  of  predilection  for  the 
cicatricial  stricture  was  at  the  cardia,  and  when  there  were  more  than  one, 
the  next  most  freciuent  site  was  the  upper  orifice,  the  tightest  being  at 
the  cardia.  In  the  author's  experience,  he  has  ne\er  seen  a  case  of  stric- 
ture due  to  caustic  situatetl  at  the  cardia.  Uut  of  a  total  of  21  of  this 
class  of  cases,  18  were  in  the  middle  third  of  the  esophagus,  ti  at  the 
level  of  the  hiatus,  4  near  the  cricopharyngeus.  Where  the  strictures 
were  multiple  they  were  usually  quite  close  together,  though  in  three 
cases  there  was  a  stricture  just  below  the  cricoid  and  another  in  the 
middle  third.  Uf  the  cases  in  the  midlle  third,  the  most  frequent  site 
was  at  about  the  crossing  of  the  left  bronchus.  Stricture  of  the  pylorus 
as  well  as  of  the  esophagus  following  the  swallowing  of  a  corrosive  has 
been  reported  by  Hruel.  (  Bib.  ."iU.) 

Prognosis.  I'lUreated,  the  mortality  of  cicatricial  strictures  of  small 
lumen  is  very  high.  Slighter  degrees  of  stenosis  are  prone  to  increase 
from  stasis,  esophagitis  and  secondary  ulceration.  By  early  gastrostomy 
witii  proper  feeding  inrough  the  tube,  life  may  be  prolonged  indefinitely. 
As  a  matter  of  fact,  however,  old  people  who  have  worn  a  gastrostomy 
tube  since  childhood  are  never  seen.  Statistics  from  which  the  causes 
of  death  might  have  been  determined  are  lacking.  Doubtless  mortality 
would  have  been  less  if  gastrostomy  had  been  done  earlier.  Under  blind 
methods  of  treatment  the  patient  was  almost  certain,  sooner  or  later,  to 
succumb  to  perforation  by  the  bougie,  the  danger  increasing  as  the  super- 
jacent dilatation  increased,  rendering  more  and  more  difficult  the  finding 
of  the  strictural  orifice.  The  i)rognosis  of  cicatricial  stenosis  of  the  esojjh- 
agus  untreated  is  unfavorable  so  far  as  recovery  is  concerned.  There 
probably  is  never  a  comjilete  spontaneous  recovery.  Occasionally  slight 
Strictures  may  become  temporarily  stenosed  with  food,  or  the  stenosis 
may  be  increased  by  swelling,  producing,  for  a  short  period,  a  very  severe 
.stenosis.  This  m:iy  subside  .'md  a  condition  of  relative  cure  so  far  as 
dysphagia  is  concerned  may  result,  and  the  patient  rnay  be  quite  comfort- 
able;  but  this  is  only  the  disappearance  of  a  relatively  temporary  condi- 
tion. In  regard  to  danger  to  life,  the  prognosis  in  cicatricial  stenosis  of 
the  esojjhagus  is  good  if  an  early  ga>trostomy  is  done  and  (he  feeding 


526  DISEASES  OF  THE  ESOPHAGUS. 

is  carefully  followed  out  according  to  a  well  planned  dietary'.  The  fore- 
going represents  the  prognosis  of  cicatricial  stenosis  before  the  develop- 
ment of  endoscopic  treatment.  L'nder  modern  methods  the  prognosis  is 
favorable  as  to  ultimate  results,  though  some  of  the  cases  require  a  long 
period  of  treatment,  the  duration  depending  upon  the  number  of  strictures, 
the  presence  or  absence  of  pouches  between  the  strictures  and  the  previ- 
ous duration  of  the  condition,  as  well  a;  upon  the  tightness  of  the  stricture. 
In  recent  cases  where  there  is  but  a  single  stricture  or  two  strictures,  the 
lower  one  of  concentric  lumen,  the  cure  is  rapid  and  the  results  excellent. 
On  the  other  hand,  in  multiple  strictures,  not  concentric,  and  of  long- 
standing, with  extensive  tibrotic  changes  in  the  esophageal  wall,  due  to 


Fig.  417. — Photograph  of  a  child,  twenty  months  old,  a  victim  of  cicatricial 
esophageal  stricture.  It  is  in  the  act  of  inducing  vomiting  by  the  insertion  of  its 
fingers  to  the  fauces,  a  self-discovered  means  of  relief,  quite  remarkable,  consider- 
ing the  age.    Referred  by  Dr.  F.  LeMoyne  Hupp. 


prolonged  chronic  esophagitis,  and  especially  if  the  lumen  of  the  stricture 
is  exceedingly  small — in  all  such  cases,  the  treatment  is  ver\-  much  more 
difficult,  and  though  the  ultimate  prognosis  is  not  unfavorable,  the  treat- 
ment will  be  prolonged  by  recurrences.  As  to  mortality  under  endoscopic 
methods,  the  author  has  never  yet  lost  a  case.  The  only  death  occurring 
in  his  clinic  was  from  blind  bouginage  before  his  present  endoscopic 
technic  was  developed. 

Symptoms.  Lengthy  consideration  of  the  symptoms  is  not  now- 
necessary,  as  it  was  in  the  days  of  the  often  erroneous  deductive  diag- 
nosis. If  a  patient  has  any  trouble  in  swallowing  or  regurgitates  or 
"vomits"  his  food  01  chokes  or  coughs  when  attempting  to  swallow, 
esophagoscopy  is  indicated  and  deductive  or  blind  instrumental  attempts 


DISEASES  OF  THE  ESOPHAGUS.  527 

at  diagnosis  are  time-wasting,  misleading  and  utterly  useless.  It  requires 
but  a  few  minutes  w-ithout  an  anesthetic,  general  or  local,  to  look  at  the 
eso]>hagus  with  the  esophagoscope  and  make  a  positive  diagnosis  of  cica- 
tricial stricture.  Radiography  is  useful  in  excluding  aneurysm  and  in  de- 
termining the  presence  of  a  stenosis  and  the  extent  of  the  dilatation  above 
it.  That  the  stricture  is  cicatricial  can  be  determined  only  by  esophagos- 
cnpy.  The  most  usual  comjilaints  of  the  patients  are  difticulty  in  swal- 
lowing, cough,  and  regurgitation.  Distress  after  eating,  to  be  relieved 
only  by  regurgitation  is  seen  in  low  strictures  (Fig.  -ll'i  ). 

Esopliagosco/yic  af^pearances  and  diagnosis  of  cicatricial  stricliirc.  The 
endoscopic  picture  in  a  typical  case  is  easily  recognized,  but  it  may  be 
masked  by  various  conditions  other  than  the  cicatrix.  If  there  is  com- 
plete stagnation,  or  if  the  patient  has  recently  eaten,  fragments  of  food 
may  be  noticed  adherent  to  the  walls  of  the  esophagus,  or  lodged  in  the 
pockets  existing  below  the  first  stricture,  or  in  the  case  of  a  recent  and 
illy-masticated  meal  there  may  be  (|uite  an  accumulation  above  the  stric- 
ture. (Jften  it  will  be  found  that  the  patient  has  come  for  a  complete 
stenosis,  which,  upon  examination  is  found  to  be  due  to  the  lodgment 
of  a  particle  of  food  acting  as  a  cork  in  the  lumen  of  the  stricture.  This 
does  not  occur  as  often  as  might  be  supposed  for  the  reason  that  the 
patients  usually  learn  that,  by  inserting  their  finger  back  uf  the  tongue  and 
causing  a  regurgitation,  food  particles  can  be,  in  most  instances,  dislodged 
and  regurgitated.  If  the  food  has  remained  for  any  length  of  time  in  the 
esophagus,  decomposition  has  occurred  and  in  case  of  nitrogenous  fooil, 
the  odor  may  W  very  foul.  In  case  of  starchy  foods  and  sugar,  there 
will  be  usually  a  sour  odor.  This  is  not  the  normally  sour  odor  of 
stomach  contents,  but  a  peculiar  odor  due  to  the  fermentation  of  starches 
and  sugars.  .Ml  food  and  sccretinns  must  be  removed  and  the  mucosa 
sponged  clean.  If  there  has  been  no  stagnation  the  color  of  the  cicatricial 
pf)rtion^  of  the  esojihageal  wall  is  usually  paler  than  normal,  and  may  be 
decidedl}  white  and  blanched.  \^essels  are  often  \i^iblc  in  tliis  white  tis- 
sue. In  certain  cases  there  may  be  patches  of  reddish,  acutely  inflamed 
mucosa,  and  if  there  is  very  much  dilatation  above  the  stricture,  there  may 
be  a  macerated  condition  of  the  esophageal  mucosa.  Where  the  mucosa 
has  been  uninjured  by  the  caustic,  the  epithelium  may  be  furred  up  and 
pasty  in  appearance  from  maceration.  The  ei)ithelium  covering  the  cica- 
tricial tissue  does  not  usually  fur  up  to  the  same  extent  and  may  be  quite 
smooth  and  shining  in  marked  contrast  to  the  furred  epithelium  in  the 
])ortions  undamaged  by  the  corrosion.  Whitish  spots  of  erosion  and  c\en 
ulceration  may  be  visible  at  certain  points  I  Fig.  12,  Plate  III).  It  is 
(|uite  likelv  that  these  erosions  play  an  iiiiportanl  part  in  lb',-  increase  of 


5*<JS  DISEASES  OF  THE  ESOPHAGUS. 

the  stenosis  and  the  diminution  of  the  strictural  lumen  through  contrac- 
tion and  fibrosis  of  the  round-celled  inflammatory  infiltrate,  constituting 
what  the  author  has  called  a  "vicious  circle."  The  scars  from  the  swallow- 
ing of  caustics  in  some  instances  are  linear  and  seen  in  perspective,  they 
appear  wedge-shaped  from  foreshortening  (Fig.  12,  Plate  III  and  Fig. 
4,  Plate  III,  Bib.  2()9).  They  are  in  some  instances  depressed  below  the 
surface  of  the  mucous  membrane,  though  in  other  instances  they  may 
project  toward  the  lumen  in  a  more  or  less  cord-like  way.  In  other  cases 
they  are  flush  with  the  neighboring  mucosal  surface.  In  passing  down  a 
cicatricial  esophagus  very  often  there  is  a  very  noticeable  absence  of  the 
normal  radial  creases.  The  cicatricial  tissue  in  a  cicatricial  stenosis  may 
take  the  form  of  a  band  running  across  in  any  direction  and  causing 
more  or  less  flattening  of  the  circular  outline  of  the  lumen  at  that  point 
Exactly  annular  strictures  occur  and  occasionally  they  are  most  beauti- 
fully .symmetrical  and  funnel-shaped.  As  a  rule,  however,  they  are  more 
or  less  eccentric,  and  their  outline  is  more  or  less  oval,  or  angular.  Where 
the  amount  of  cicatricial  tissue  is  small,  the  outline  is  not  fixed  but 
changes  with  the  respiratory  movements  and  even  with  the  transmitted 
cardiac  impulses,  antiperistalsis  and  movements  imparted  by  the  esophago- 
scope.  If  the  first  stricture  encountered  is  not  very  smal!,.  the  view 
through  the  stricture  usually  is  that  of  a  cavity  below.  In  this  cavity  it 
is  very  rare  to  see  the  lumen  of  strictures  which  usually  exist  below,  be- 
cause the  lower  ones  are  not  concentric  with  the  upper  ones,  nor  are  their 
lumina  easy  to  find.  If  the  upper  stricture  is  not  very  tight  and  the 
lower  one  is  smaller,  there  is  a  strong  tendency  to  pouch  formation  from 
the  pressure  of  food  accumulating  between  the  two  strictures. 

Differential  diagnosis.  In  a  typical  case,  a  cicatricial  stenosis  is 
readily  recognizable  by  the  descriptions  already  herein  given,  but  there 
are  cases  in  which  a  diagnosis  is  extremely  difficult  because  of  associated 
lesions.  When  inflammatory  conditions  and  ulceration  are  present,  they 
must  be  first  treated  by  a  rest  in  bed,  very  careful  restriction  of  the 
diet  as  to  quantity,  and  all  food  should  ue  licjuid.  Bismuth  and  calomel 
taken  dry  on  the  tongue  in  small  quantities  at  frequent  intervals,  with 
liquid  diet,  will  cure,  in  most  cases,  the  esophagitis  with  erosions  and 
ulcerations  that  accompany  stenotic  conditions.  In  addition  to  this,  local 
apjilication  of  argyrol  to  ulcerations  and  to  granulation  surfaces  will  aid 
in  clearing  uj)  these  lesions.  The  cicatricial  nature  of  the  stenosis  then 
becomes  quite  apparent.  Cancerous  stenosis  is  accompanied  by  infiltra- 
tion and  a  distortion  of  the  shape  of  the  lumen  of  the  esophagus,  which. 
even  in  the  absence  of  open  ulceration,  is  (|uite  different  from  the  thin 
at  times  almost  membranous  cicatricial  stenosis.  Im])ermeable  cicatri- 
cial stenosis  may  seem  hard,  Ijut  cancer  rarely  is  impermeabie  until  late. 


DISEASES  OF  THE  ESOPHAGUS.  529 

and  in  cancer,  there  are  usnally  nrojecting  fungations  and  edematous 
polypoid  masses,  when  the  disease  has  reached  a  condition  of  severe 
stenosis.  Prior  to  this  time,  infiltration  of  the  esophageal  wall  is  quite 
apparent  to  palpation  with  the  tube  and  probe.  Moreover,  in  cancer 
there  is  more  or  less  of  fixation  of  the  entire  esophagus,  which  does  not 
yield  readily  laterally  to  manipulations  of  the  tube.  It  is  necessary,  how- 
ever, to  remember  that  cancer  may  develop  at  the  site  of  a  cicatrix,  as 
evidenced  by  the  following  case : 

Robert  M.,  aged  ~i8  years,  applied  for  admission  to  the  Western 
Pennsylvania  Hospital  for  difficulty  in  swallowing,  which  had  persisted 
with  variations  in  degree  since  the  healing  of  a  l)ullct  wound  20  years 
before.  Within  the  last  few  months,  there  had  been  a  steady  increase  un- 
til only  liquids  could  go  down.  There  was  a  depressed  wound  in  the 
neck  on  the  right  side,  and  a  scar  three  inches  in  length  on  the  left  side 
corresponding,  according  to  the  patient's  statement,  to  the  site  of  an  oper- 
ation to  remove  the  bullet  which  had  not  emerged.  The  patient  stated 
that  immediately  following  the  injury,  he  had  noticed  no  bleeding,  but  he 
had  vomited  material  like  coffee  grounds  not  long  after.  On  passing  the 
esophagoscope,  I  found  a  pharyngeal  pouch  or  diverticulum.  The  sub- 
diverticular  opening  was  in  the  usual  location,  anterior  to  the  pouch.  This 
opening  was  large,  admitting  a  10  mm.  esophagoscope  for  about  5  cm. 
At  this  level,  the  esophagus  deviated  very  markedly  to  the  left,  the  walls 
were  tightly  adherent  and  there  was  a  stricture  of  oval  outline  with  a  flat 
ulceration  of  about  1  cm.  in  diameter,  just  touching  the  right  strictural 
margin.  1  excised  the  edge  of  this  ulcer,  including  a  portion  of  the 
stricture.  Examination  of  this  tissue  by  Joseph  H.  Barach,  showed  it  to 
be  a  squamous-celled  epithelioma. 

Remarks.  It  is  quite  clear  from  the  foregoing  history  that  a  cicatri- 
cial stricture  existed  for  18  or  1!)  years,  and  that  the  cicatricial  tissue  be- 
came the  site  of  the  implantation  of  the  cancerous  process.  Whatever 
may  be  our  ideas  concerning  irritation  as  a  factor  in  the  development  of 
carcinoma,  there  can  be  no  doubt  that  cicatricial  tissue  and  chronic  in- 
flammatory conditions  offer  a  favorable  soil  for  the  development  of  can- 
cer. The  develo])ment  of  a  diverticulum  from  cicatricial  stenosis  is 
worthy  of  note  as  a  very  rare  observation. 

In  comi)ression  sienosis  of  the  eso|)hagus,  the  lumen  does  not  taper 
down  to  a  point  as  in  strictures,  and  the  outline  of  the  lumen  is  linear 
and  more  or  less  cresccntic,  from  the  bulging  inward  of  one  wall  convexly 
from  one  side  (Fig.  7,  Plate  III,  Bib.  2G9),  though  occasionally  it  is 
seen  as  a  flattening  of  the  walls  with  a  more  or  less  straight  long  dia- 
meter. L'nless  the  compression  is  from  a  very  firm  growth,  a  small 
esophagoscope  can  usually  be  insinuated  through  the  compression,  and 


530  "OISKASKS  OF  THK  ESOPHAGUS. 

the  mucosa  below  will  be  found  to  be  normal.  The  mucosa  above  in 
cases  of  severe  compression,  may  show  the  signs  of  chronic  esophagitis 
which  accompany  stasis  and  maceration.  Ordinarily,  however,  compres- 
sions are  characterized  by  normal  mucosa,  which  is  in  marked  contrast 
to  the  thin  white  appearance  of  the  strictural  margin.  Spasmodic  stenoses 
are  characterized  by  a  wrinkling  of  the  esophageal  lumen  which  throws 
the  membrane  into  folds,  and  the  crevices  between  these  folds  taper  down 
to  a  vanishing  point,  as  shown  in  Fig.  7,  Plate  III.  Moreover,  gentle 
pressure  continued  for  a  time  will  cause  the  spasmodic  stenosis  to  yield 
and  tlie  esophagoscope  w  ill  pass  on  through.  The  mucosa  below  is  usual- 
ly normal,  while  that  above  may  be  more  or  less  altered  by  chronic 
esophagitis ;  but  the  diagnostic  point  is  the  opening  up  of  the  constricted 
area  to  the  full  lumen  as  soon  as  the  spasm  yields  to  pressure.  General 
anesthesia  may  be  used  to  overcome  spasm,  but  this  is  rarely,  if  ever, 
necessary  for  the  skilled  esophagoscopist.  though  until  skill  is  acquired, 
great  caution  is  necessary  in  applying  any  pressure  on  the  supposition 
that  a  condition  is  spasmodic  stenosis. 

Treatment  of  cicatricial  stenosis  of  the  esophoAjns.  In  dealing  with 
the  esophagus,  it  must  always  be  remembered  that  it  is  one  of  the  most 
intolerant  organs  with  which  we  have  to  deal  surgically.  Shock  is  out 
of  all  proportion  to  the  extent  of  the  operation  or  of  the  lesion,  as  shown 
in  ordinary  acute  esophagitis  from  traumatism.  I'herefore,  we  must  not 
undertake  treatment  without  due  preparation  of  the  patient  as  regards 
everything  that  concerns  his  strength  and  endurance.  If  the  patient  has 
not  already  been  gastrostomized,  it  is  wise  to  keep  a  very  close  watch 
on  the  state  of  his  nutrition  during  any  form  of  treatment.  It  is  always 
possible  for  local  reaction  to  entirely  shut  up  the  esophagus,  and  the 
patient  will  very  quickly  suffer.  Procedures  are  so  much  simplified  by 
having  the  patient  regularly  fed  through  a  gastrostomic  tube  and  the 
putting  of  the  esophagus  at  rest  is  so  beneficial  that  there  should  be  no 
hesitation  in  advising  it  in  the  worst  cases.  In  most  instances,  however, 
a  lumen  for  lic|uids  remains,  ami  with  care  in  diet,  gastrostomy  will 
rarely  be  necessary.  The  general  preparation  of  the  patient,  as  men- 
tioned on  a  preceding  page,  should  be  carried  out  as  a  preliminary  to  any 
operation  or  examination  on  the  esophagus.  In  addition  thereto,  abso- 
lute rest  of  the  esophagus  to  reduce  the  esophagitis.  is  an  essential  oper- 
ative preliminary.  Absolutely  nothing  but  water,  milk,  ice  cream  and 
consomme  should  be  allowed,  and  bismuth  subnitrate  with  a  little  calomel 
from  time  to  time  should  be  swallowed  dry,  in  small  doses  at  fret|uent  in- 
tervals. Patients  in  a  state  of  water  hunger  make  exceedingly  bad 
surgical  subjects,  and  absolutely  no  attempt  at  endoscopy  should  be  un- 
dertaken until  the  patient  has  fully  recovered  from  food  and  water 
starvation  as  before  mentioned. 


DISF.ASKS  OP  TIIK  I-SOPIIAGUS.  531 

The  question  arises:  To  what  extent  shall  dilatation  of  a  stricture 
he  carried  out?  This  must  be  determined  by  the  functional  result.  In 
some  cases  it  is  necessary  to  produce  a  very  large  opening  because  of  the 
sacculation  almost  amounting  to  a  diveiticulum  above  the  stricture.  In 
one  of  the  author's  cases,  this  was  so  great  that  it  pressed  on  the  lumen 
of  the  esophagus  below  the  stricture  and  interfered  with  swallowing  to 
such  an  extent  that  it  was  necessarj-  to  bite  out  the  spur  with  forceps  so 
as  to  obliterate  the  bottom  of  the  sack.  In  this  case,  the  stricture  was  in 
the  neck.  It  is  questionable  whether  such  a  procedure  would  be  justifi- 
able in  the  thorax.  In  another  case  a  valve-like  fold  overhanging  the 
lumen  of  the  stricture  required  removal.  In  cases  in  which  there  is  very 
little  sacculation,  a  relatively  small  opening  will  give  an  excellent  func- 
tional result,  and  if  an  opening  of  six  or  seven  millimeters  can  be  main- 
tained, the  patient  will  have  no  trouble  functionally,  if  food  is  perfectly 
masticated.  Imperfectly  masticated  food  of  any  kind,  of  course,  be- 
comes a  foreign  body.  The  author  has  had  cases  that  would  sw-allow  all 
kinds  of  food  when  properly  masticated  but  their  esophagus  would  be- 
come occluded  from  the  swallowing  of  the  pulp  of  a  grape  containing  the 
seeds.  A  number  of  times  when  this  has  occurred,  maceration  and  soft- 
ening of  the  ]ju1i)  of  the  grape  has  allowe<l  the  seeds  to  go  through  and 
the  stenosis  to  be  relieved,  but  of  course  foods  of  this  kind  should  not 
be  partaken  of.  In  two  other  instances  an  orange  seed  lodged  between 
the  upper  and  the  lower  stricture  in  a  jjatient  that  for  many  months  be- 
fore hacl  been  having  no  trouble  wliale\er  with  eating  all  kinds  of  food. 
After  the  author  removed  the  orange  seed,  no  further  trouble  was  ex- 
perienced, though  two  years  have  now  elaj)sed  in  one  case,  and  a  year  in 
the  other,  during  which  time  the  patients  have  been  partaking  of  all 
kinds  of  food  thoroughly  masticated.  These  cases  show  how  small  a 
lumen  may  suffice.  It  may  be  said,  then,  tliat  the  degree  of  dilatation 
should  be  determined  altogether  functionally.  Having  obtained  good 
useful  swallowing,  it  is  questionable  in  some  cases  whether  it  is  wise  to 
persist  in  an  attempt  entirely  to  obliterate  the  stricture  and  restore  full 
lumen,  which  involves  more  risk  to  the  patient  than  is  involved  in  the 
obtaining  of  a  useful  lumen.  A  good  functional  result  is  better  de- 
termined by  a  bismuth  radiography  or  fluoroscopy  than  by  the  sensations 
of  the  patient.  The  stomach  should  be  empty  of  food  ( it  is  never  entirely 
empty  of  secretion  )  and  the  bowels  should  be  freely  emptied  by  an  enema 
before  any  ojierative  jirocedure  upon  the  esophagus.  There  is  a  disposi- 
tion on  the  part  of  the  profession  to  disregard  this  common  preoperative 
precaution  in  patients  who  have  been  unable  to  swallow  any  food  for 
several  days.  No  anesthesia,  general  or  local,  is  needed  and  as  any  form 
of  treatment  has  to  be   frequentlv  repeated,  all    hirms  of  anesthesia  are 


533  DISEASES  OF  THE  ESOPHAGUS. 

contraindicated.  The  problem  is  to  determine  the  best  method  of  get- 
ting a  start  in  the  dilatation  of  strictures  of  exceedingly  small  lumen,  say 
one  or  two  millimeters  in  diameter.  There  have  been  many  dilators  and 
divulsors  devised,  most  of  which  can  only  be  used  in  stricture  of  such 
large  lumen  (say  six  or  seven  mm.)  that  they  do  not  urgently  need 
dilatation.  Such  instruments  are  of  use  in  hiatal  and  abdominal  esopha- 
gismus,  but  cicatricial  esophageal  strictures  of  large  lumen,  or  those  in 
which  a  good  start  has  been  obtained,  are  of  easy  management,  and  the 
choice  of  methods  is  of  little  moment.  Small  almost  impermeable  stric- 
tures on  the  contrary  are  extremely  difficult  to  dilate  in  the  first  stages 
of  the  work.  Personally  the  author  has  found  nothing  equal  to  bougin- 
age  per  tubam. 

Bonginage  per  tubam.  The  author  uses  the  double  olive  bougies 
(Fig.  61,  p.  108,  Bib.  2G9 )  only  in  the  most  minute  strictures  and  then 
only  to  get  a  start.  In  almost  all  cases  the  start  can  be  matle  and  the 
treatment  continued  with  the  filiform  bougie  jiermanently  mounted  on 
the  steel  stem  (Fig.  53).  Three  or  four  successively  larger  sizes  can 
be  used  at  one  seance.  The  last  and  largest  bougie  that  can  be  safely 
inserted  is  left  in  for  about  twenty  minutes,  the  esophagoscope  being 
withdrawn,  if  desired,  after  the  bougie  is  placed.  At  the  next  treatment 
about  two  days  later  the  start  can  usually  be  made  with  a  bougie  one  or 
two  sizes  larger  than  the  starting  size  at  the  previous  treatment.  Treat- 
ments are  continued  at  intervals  of  a  few  days  until  the  largest  size  that 
can  be  inserted  through  the  esophagoscope  can  be  inserted  and  with- 
drawn without  resistance.  The  patient  is  then  ready  for  the  daily  swal- 
lowing of  a  common  bougie  of  the  old  type.  Under  no  circumstances 
should  he  push  it.  It  should  be  precedetl  by  the  swallowing  of  about  10 
cc.  of  olive  oil  for  lubrication.  After  three  or  fourth  months  the  interval 
may  be  lengthened  to  a  week  or  two,  liut  must  not  be  abandoned  for  a 
year.  Even  then  a  monthly  passage  is  advisable  for  the  early  detection 
of  any  tendency  to  recurrence.  In  children  the  size  must  be  increased 
from  year  to  year  proportionate  to  the  normal  esophageal  growth  and 
development.  The  foregoing  is  the  author's  method  in  all  cases  where 
the  stricture  is  single  and  also  in  all  cases  of  multiple  stricture  in  which 
the  lumina  of  the  lower  strictures  are  concentric  with  the  upper  one. 
The  most  difficult  cases  to  treat  are  those  in  which  there  are  many 
strictures,  and  especially  where  the  lumen  of  the  stricture  is  not  con- 
centric nor  in  line  with  each  other.  In  addition,  there  may  be  more  or  less 
sacculation  between  the  strictures  rendering  it  extremely  difficult  to  find 
the  aperture  of  the  strictures  below  the  first  as  shown  in  Fig.  41S.  The 
author's  method  of  dealing  with  these  strictures  is  to  dilate  first  the 
upper  one    forcibly   and  widely,   then   take   the   second   one   which   now 


DISEASES  OF  THE  ESOPHAGUS. 


533 


comes  into  view  because  a  small  tulie  can  be  put  through  the  first  one, 
which  lias  been  dilated.  l"or  tliis  jiurpose  none  of  the  divulsors  to  be  had 
are  of  any  use.  They  do  not  stretch  at  the  very  end.  so  that  thev  must 
be  inserted  far  beyond  the  stricture  to  obtain  any  divulsion.  Such  inser- 
tion is  impossible  in  the  most  difficult  class  of  cases  with  which  we  have 
to  deal :  namely,  multiple  eccentric  strictures,  because  the  second  stric- 
ture will  prevent  the  insertion  of  the  instrument  far  enough  to  obtain 
any  divulsion  on  the  first  stricture.     For  this  reason,  the  author  has  de- 


FiG.  418. — Sclicniatic  illustration  of  a  series  of  eccentric  strictures  with  in- 
terstrictiiral  sacculations,  in  the  esophagus  o£  a  boy  of  four  years.  Divulscd 
seriatim  from  above  downward  with  the  divulsor  (Fig.  52),  the  esophageal  wall, 
D,  being  moved  sidewise  to  the  dotted  line  bj-  means  of  a  small  esophagoscopc  in- 
serted through  the  upper  stricture,  A,  after  divulsion  of  the  latter. 


vised  the  divulsor  shown  in  Fig.  .")'2.  With  this  instrument,  we  can  di- 
vulse  the  first  stricture,  e\en  though  it  be  less  than  1  cm.  away  from  the 
second  stricture.  This  is  a  safe  i>rocedurc.  because  between  the  two 
strictures  there  is  always  more  or  less  of  a  pouch,  in  using  the  word 
"safe,"'  the  author,  nf  course,  means  relatively  safe,  because  any  eso- 
phageal instrument  must  be  used  with  care  and  tactile  appreciation  of 
the  exact  amount  of  force  applied. 

Since  the  stagnation  of  food  is  the  greatest  factor  in  the  production 
of  esophagitis  in  these  cases,  it  is  necessary  that  the  diet  shall  be  care- 


534 


DISEASES  OF  THE  ESOPHAGUS. 


fully  regulated.  Food  should  be  taken  in  minute  quantities  at  a  time, 
allowing  a  long  time  for  a  meal  to  be  ingested.  Liquid  foods  only  are 
to  be  permitted  in  certain  cases.  In  other  cases,  and  later  on  in  all 
cases,  solids  may  be  used,  provided  they  be  thoroughly  masticated.  Semi- 
solids, and  especially  very  soft  boiled  eggs,  custards  and  the  like  usually 
go  down  about  as  well  as  liquids,  even  in  small  strictures.     The  patient 


¥p 

^^r '^          ^m 
^^^H^^** '''           ^ 

"'  ^il^^^^l 

1^ 

k  'J 

Hi 

Fig.  4ig. — Radiograpli  showing  cnmjilctf  cure  ot  a  cicatricial  stenosis.  The 
bismuth  mixed  with  bread  and  milk  went  through  into  the  stomach  so  promptly 
and  completely  as  not  to  show  in  this  radiograph  made  immediately  after  taking 
the  mixture.  The  gastrostomy  tube  shown  in  the  radiograph  was  immediately 
abandoned.     (Radiograph  made  by  Dr.  George  \V.  Grier.    Author's  case.) 


must  be  instrucied  that  should  any  accumulation  of  food  be  felt  it  nuist 
be  regurgitated  and  followed  by  a  glassful  of  a  weak  solution  of  sodium 
bicarbonate.  If  this  sodium  bicarbonate  does  not  go  through  promptly, 
it  should  be  regurgitated  also,  thus  accomplishing  a  lavage  of  the 
esophageal  mucosa.  Ice  cream  is  a  very  valuable  food  in  all  forms  of 
stenosis  and  in  all  stages  of  after-treatment,  not  only  because  of  the  cold, 
but  because  it  is  always  ingested  slowly.  Of  course  there  is  nothing  to 
prevent  a  patieiU  taking  any  liquid  food  slowly  by  the  teaspoonful,  but  as 


DISEASIvS  or  TIIIC  KSOr MAGUS. 


535 


a  matter  of  fact,  once  tb.e  patient  gets  away  from  the  hospital  it  is  ex- 
ceedingly diflicult  to  enforce  the  rule  of  teaspoonful  taking  of  fluids. 

Numerous  cases  illustrative  of  the  success  of  this  treatment  could 
be  cited,  but  a  few  will  suffice : 

A  hoy  of  three  years,  consulted  Dr.  E.  L.  Jones  of  Cumberland,  for 
inability  to  swallow  even  water  or  saliva  for  eight  days.  The  child 
had  swallowed  lye  eight  months  previously,  and  the  inability  to  swallow- 
had  come  on  gradually.     Dr.  Jones  immediately  referred  the  case  to  the 


Frc;.  ^2C.— I-'rnm  photugraplis  of  a  1ju\  of  Imir  Ncar.-i.  \\  ci^lu  wIk-u  first  seen 
26  pounds.  After  jStli  endoscopic  bouginage,  42  pounds.  Patient  referred  by  Dr. 
H.  T.  Price. 


author.  The  child  was  in  cvtrciiiis  and  its  life  was  saved  only  liy  a 
prompt  and  skilful  gastrostomy  by  Dr.  James  W.  .Macl'"arlane.  One 
week  later  the  author  passed  an  esophagoscope  and  found  at  the 
crico]iharyngeus  a  tight  stricture  (  1  mm.  )  which  was  divulscd  with  the 
divulsor.  Fig.  ."i'.'.  .\  second  eccentric  stricture  about  1  cm.  lower  down 
was  similarly  di\ulsed  and  bouginage  per  tubam  com])lete(l  the  cure. 
Six  seances  were  reciuired  to  restore  normal  swallowing  (Fig.  419). 
The  gastrostomy  tube  was  abandoned.  Xo  anesthesia  was  used  for  the 
treatment.  The  child  now,  otie  year  later,  is  ,ible  iirom|>tI\-  to  swallow 
any  normally  mastic.ilcd  food. 


536 


DISEASES  OF  THE  ESOPHAGUS. 


Remarks.  The  statement  of  the  parents  that  tlie  child  had  swallowed 
no  water  for  eight  days  is  probably  inaccurate.  Some  little  fluid  must 
have  leaked  through  the  stricture  or  the  child  could  not  have  survived. 

A  girl  of  two  years  was  referred  to  the  author  by  Dr.  Abraham  of 
New  York  City  for  inability  to  s^vallow  which  came  on  a  few  weeks 
after  swallowing  a  solution  of  a  washing  powder.  A  general  surgeon 
failed  to  pass  a  bougie  under  chloroform  anesthesia.  Esophagoscopy  by  the 
author  revealed  a  tight  stricture  (1  mm.  diameter)  at  about  the  crossing 
of  the  left  bronchus.     A  double  olive  bougie  could  be  felt  to  engage  in 


Fig.  421. — Same  patient  as  in  Kiy.  420.     Two  years  later. 


two  Strictures  below,  making  three  strictures  in  all.  Bouginage  per  tubam 
in  about  fourteen  treatments  cured  the  child  completely.  She  swallows 
food  the  same  as  any  child.  Now,  five  years  later  (seven  years  of  age) 
she  can  swallow  a  silk-woven  bougie,  12  mm.  diameter,  without  the 
slightest  check  to  indicate  where  the  stenosis  had  been. 

A  boy,  four  years  of  age,  was  referred  by  Dr.  H.  T.  Price  for  in- 
ability to  swallow.  Immediate  gastrostomy  by  Dr.  R.  E.  Brenneman 
saved  the  child's  life.  Esophagoscopy  by  the  author  revealed  a  stricture 
J  mm.  in  diameter.  The  smallest  double  olive  bougie  would  jjass  through 
but  was  stopped  by  occlusion  below.  Bending  the  stem  between  the  two 
olives,  enabled  the  author  by  rotation  to  find  the  lumen  of  the  stricture 


DISEASES  OK  THE  ESOPHAGUS.  537 

below,  wlicii  a  third  obstruction  was  found  (Schema  l'"ig.  418).  All 
three  eccentric  strictures  were  treated  by  the  author's  method  before 
described,  resulting  in  an  ultimate  cure.      (Figs.  4"20  and  421). 

Having  described  tlie  method  by  which  the  author  has  been  able  to 
restore  normal  swallowing  to  almost  every  patient  with  a  permeable 
eso[)hagus,  some  other  esophagoscopic  methods  may  be  described.  Blind 
methods  are  not  within  the  scope  of  this  book. 

Internal  esophagotomy  is,  in  the  opinion  of  Killian  and  of  the  au- 
thor, an  extremely  dangerous  procedure.  If  justifiable  at  all  it  is  only 
so  in  the  hands  of  the  most  experienced  and  skillful  esophagoscopists.  It 
is  necessary  ocularly  to  recognize  and  cut  cicatricial  tissue  only,  never 
the  normal  esophageal  wall.  This  recognition  is  not  always  easy  and  may 
be  impossible.  Personally,  the  author  does  not  use  internal  esophagotomy 
because  he  deems  theoretically  that  dilatation  subsecjuent  to  incision  would 
be  very  apt  to  result  in  a  tear  taking  its  start  from  the  incision.  In  the 
absence  of  an  incision  forcible  dilatation  carried  out  with  reasonable 
care  and  esjjecially  with  an  acute  tactile  sense,  need  never  tear  cicatricial 
tissue.  The  author  used,  endoscopically,  in  a  number  of  cases  (Bib.  257) 
the  string-cutting  esopbagotome,  Fig.  51,  without  mortality  or  serious 
symptoms,  but  the  abo\e  outlined  methods  are  so  satisfactory  as  to  leave 
little  to  be  desired.  The  author's  esopbagotome  (Fig.  51)  can  be  turned 
so  that  the  cutting  by  the  to-and-fro  motion  of  the  string  will  be  only 
on  the  manifest  cicatricial  part  of  the  stricture.  Guisez  (Bib.  178)  re- 
ports excellent  results  from  internal  esophagotomy. 

Electrolysis  has  yielded  excellent  results  in  the  hands  of  (luisez  (  Bib. 
178). 

String  s7callozvin<j.  So  far  the  author  has  never  yet  encounlercil  a 
case  in  which  he  could  not  esophagoscopically  find  the  lumen  in  any 
stenotic  case  that  had  a  lumen.  If  the  lumen  could  not  be  found,  doubt- 
less the  string  swallowing  method  of  Sippey  could  be  adapted  to  esoph- 
agoscopic use,  the  esophagoscope  being  threaded  over  the  proximal  end 
of  the  string,  the  distal  end  having  been  swallowed  some  days  before. 

Retrograde  esopliagoscopy.  The  first  step  is  to  get  rid  of  the  gas- 
tric secretions.  There  is  always  fluid  in  the  stomach,  and  this  keeps 
pouring  out  of  the  tube  in  a  steady  stream.  Fold  after  fold  is  emptied 
of  fluid.  Once  the  stomach  is  empty,  the  search  begins  for  the  cardial 
0[)ening.  When  it  is  desired  to  do  a  retrograde  esophagoscopv  and  the 
gastrostomy  is  done  for  this  special  [)urpose,  it  is  wise  to  have  it  very 
high.  Once  the  cardia  is  located  and  the  eso])hagus  entered,  the  remain- 
der of  the  work  is  very  easy.  Piouginage  can  be  carried  out  from  below 
the  same  as  from  above.     It  has  been  claimed  that  bouginage  from  below 


538  DLSICASES  OF  TlliC  KSOPHAGUS. 

is  easier  because  there  is  never  any  dilatation  below  the  stricture  to  con- 
tend with,  and  strictures  are  much  more  apt  to  be  concentric  as  ap- 
proached from  below  because  there  has  been  no  distortion  by  pressure 
dilatation  due  to  stagnation  of  the  food  operating  through  a  long  period 
of  time.  This  does  not  coincide  with  the  experience  of  the  author,  who 
has  found  peroral  treatment  of  cicatricial  stenosis  easier  and  much  more 
satisfactory  in  every  way. 

Impermeable  strictures  may  be  classified  under  three  heads. 

1.  Strictures  of  the  cervical  esophagus. 

2.  Strictures  of  the  middle  third. 

3.  Strictures  of  the  lower  third. 

The  cervical  strictures  are  readily  amenable  to  external  esophagot- 
omy  with  a  ]ilastic  operation  for  the  opening  up  and  reformation  of  the 
eso]iliagus.  The  esophagus  can  be  built  up  if  necessarv  out  of  skin  flap 
turned  inward  provided  such  flap  can  be  procured  from  a  location  free 
from  hair.  Such  a  flap  must,  of  course,  be  turned  in  without  severing 
its  attachment  totally  from  the  skin  and  rather  a  broad  pedicle  will  be  re- 
quired to  make  sure  of  the  nutrition  of  the  flap  until  it  becomes  anchored 
in  its  new  position  and  vitalized  by  a  new  blood  supply. 

Imiiermeable  strictures  of  the  middle  third  of  the  esophagus  are  not 
amenable  to  treatment  by  any  means  at  present  known,  and  the  patient 
will  have  to  be  satisfied  with  a  gastrostomy,  unil  transthoracic  esophagot- 
nmy  has  been  fully  developed.  J.  W.  Murphy  and  Samuel  Iglauer  have 
done  an  internal  esophagotomy,  the  peroral  esophagoscopist  using  the 
transillumination  of  the  light  of  the  retrograde  esophagoscopist  as  a  guide 
for  incision.  The  patient  in  this  instance  did  not  survive,  but  success 
seems  possible.  Esophagoplication  as  done  by  Willy  Meyer  and  others 
will  ameliorate  the  patient's  condition. 

In  ca.se  of  impermeable  stricture  of  the  lower  third  the  patieiu  can 
be  cured  by  an  operation  l)y  the  I5renneman  method.  The  general  sur- 
geon makes  a  new  opening  into  the  stomach,  above  the  gastrostomic  open- 
ing, and  as  high  u[)  as  possible.  The  surgeon  then  inserts  his  finger  into 
the  esophagus  u])  to  the  point  of  stricture  while  the  esophagoscopist, 
working  from  above,  inserts  his  esophagoscope  down  to  the  stricture. 
Under  these  circumstances  the  surgeon  can  feel  the  end  of  the  esophago- 
scope with  the  finger  and  is  reasonably  safe  in  cutting  through  into  the 
lumen  of  the  esophagoscope.  A  soft  rubber  stomach  tube  is  then  passed 
down  by  the  esophagoscopist,  and  seized  by  the  surgeon  from  below  or 
vice  versa.  This  stomach  tube  is  left  in  situ  for  a  few  days  and  is  re- 
placed by  attaching  with  stitches  a  freshly  sterilized  one  to  the  old  one, 
which  serves  to  pull  the  fresh  one  down  iiUo  place.     Tulies  must  be  used 


DISEASES  OF  THE  ESOPHAGUS.  539 

for  ihrcu  or  four  weeks  or  hunger  until  the  inner  surface  of  the  divided 
stricture  is  ei)itheHalize(l.  Then  bouginage  per  tiibam  must  be  used  to 
maintain  the  opening.  Jn  the  author's  case  of  this  kind  a  very  promising 
result  failed  of  ultimate  cure  because  of  neglect  of  the  patient  to  return 
regularly  for  bouginage.  The  really  difficult  part,  the  esophagotomy  done 
by  Dr.  K.  E.  Crtnneman.  was  an  unqualified  success. 

lutuhatiun  of  the  csopluujus  has  been  very  successful  in  the  hands 
of  Guisez,  whose  excellent  soft  rubber  tube  lor  the  purpose  is  illustrated 
in  connection  with  esophageal  intubation.  ( q.  v.  I  Briinings  uses  a 
urethral  bougie  passed  with  a  stilette  having  a  thread,  on  which  travels 
a  nut,  which  thus  makes  an  adjustable  shoulder  pre\enting  the  stilette 
reaching  the  extreme  end  of  the  bougie.  A  hole  is  burned  w'ith  a  hot 
wire  in  the  proximal  end  of  the  bougie  for  the  insertion  of  a  silk  thread 
for  the  withdrawal  The  bougies  are  allowed  to  remain  in  situ  about  an 
hour. 


CHAPTER     XXXIII. 

Diseases  of  the  Esophagus.     Continued. 

DlVEiJTICUI.UM    OF  THE  EsOP MAGUS. 

Diverticula  have  been  classified,  according  to  their  supposed  etiology, 
into  traction  and  pulsion  diverticula.  The  traction  variety  is  situated 
usually  within  the  thorax  and  is  due  to  the  adherence  of  cicatricial  tis- 
sue;  the  pulsion  diverticulum  is  situated  in  the  neck  but  may  extend  to 
the  upper  thoracic  aperture. 

Traction  diverticiilitin  of  tJie  csopluuius  is  a  rare  condition  and  still 
more  rare  is  its  endoscopic  discovery,  because  it  usually  causes  no  symp- 
toms. 

The  etiolog}'  of  traction  diverticula  is  very  concisely  stated  by  Arthur 
Keith,  as  follows:  "1.  A  localized  adhesion  of  the  esophagus  to  the  sur- 
rounding part,  usually  due  to  inflammation  of  one  of  the  bronchial  glands. 
2.  Traction  of  this  adhesion  which  occurs  during  coughing,  deep  inspira- 
tion and  deglutition.  In  these  acts  the  trachea  and  the  esophagus  move 
independently  and  elongate  the  adhesion  formed  between  them  with  the 
result  that  traction  diverticula  of  the  esophagus  are  formed." 

Traction  diverticula  are  very  much  less  likely  to  be  discovered  than 
pulsion  diverticula  because  thev  are,  as  a  rule,  much  less  in  depth  and 
constitute  really  a  localized  one-sided  enlargement  of  the  tube,  scarcely 
amounting  to  a  true  pouch.  Unless  the  esophagoscope  is  kept  moving 
laterally  from  one  side  to  the  other,  they  may  easily  escape  discovery  in 
the  folds  of  mucosa,  unless  a  ver}-  large  esophagoscope  be  used,  so  as  to 
dilate  the  esophagus  nearlv  to  a  full  normal  lumen.  Once  the  diverticulum 
is  found,  unlike  in  pulsion  diverticulum,  the  sub-diverticular  lumen  is 
easily  found  and  followed,  because  it  gapes  on  inspiration  and  it  is  not 
slit-like,  because  there  is  not  the  same  subjacent  orbicular  muscular  con- 
traction, nor  is  there  resistance  to  movement  of  the  esophagoscope  in  any 
direction.     In  some  instances  lateral  movements  of  the  tube  will  discover 


DISEASKS  OF  THE  ESOPHAGUS.  541 

tliat  the  esophagus  is  adherent  tn  a  peri-esophageal  mass.  The  mucosal 
appearances  may  be  the  same  as  in  pulsion  diverticulum.  The  author  has 
seen  but  one  case  which  was  as  follows : 

A  man  of  48  years  was  referred  by  Dr.  MacCandless  for  choking 
on  swallowing,  which  symptom  was  of  two  months'  duration.  There  was 
profuse  and  foul  expectoration.  The  left  vocal  cord  was  paralyzed,  and 
the  left  arytenoid  was  atrophied,  bronchoscopy  showed  a  mass  of  granu- 
lation tissue  in  the  left  bronchus  and  a  traction  diverticulum  in  the 
esophagus  with  a  mass  of  granulation  tissue  on  the  border  of  an  ulcer 
through  which  air  leaked  into  the  esophagus  when  the  patient  coughed, 
'i'lie  divcrticidimi  consisted  of  a  pouch-like  dilatation  of  the  anterior  wall 
of  the  esophagus  above  the  crossing  of  the  left  bronchus.  There  was  no 
stenosis  below  the  diverticulum.  No  spasm  was  apparent  at  esophago- 
scopy,  and  the  esophagoscope  of  full  adult  size  could  be  introduced  all 
the  way  to  the  stomach.  A  specimen  of  the  granuloma  was  removed 
through  the  esophagoscope.  Milk  was  found  bronchoscopically  in  the 
l)ronchi  after  swallowing.  The  patient  died  of  exhaustion  three  months 
later  at  his  lionic.  Autopsy  was  not  permitted.  Evidently  the  symptoms 
were  produced  by  leakage  of  food  into  the  bronchi.  Examination  of  the 
removed  tissue  by  Dr.  Ralph  Duffy  showed  it  to  be  tuberculous.  There 
is  no  available  treatment  for  traction  diverticula.  Fortunately  they  rarely 
require  treatment,  l)ecause  they   rarely  pro<luce  symptoms. 

Pulsion  I)i\i;rticulum  of  thi-;  Esoi'iiagus. 

i'ulsion  diverticula  of  the  esophagus  are  usually  small  and  may  not 
Ije  larger  than  1  or  2  cubic  cm.  capacity.  On  the  other  hand,  they  may 
be  quite  large  and  may  bulge  out  the  neck  like  a  large  and  low  goitre, 
especially  w  lu-n  lilled  with  food.  See  Fig.  42.").  Tbcy  may  be  centrally 
located  behind  the  cervical  esophagus,  l)ut  usuallv  their  bulk  is  to  one 
side,  more  often  the  left  side. 

liliolof/x.  I'ulsion  diverticulum  is  essentially  a  hernial  sac  caused 
by  [iressure  of  the  food  bolus  at  a  point  where  the  wall  is  weakly  sup- 
ported, as  will  be  understood  from  the  schema.  Fig.  422.  The  llrm  con- 
traction of  the  cricopharyngeus  may  be  realized  by  tlie  firmness  with 
which  the  cricoid  cartilage  is  pulled  backward  against  the  vertebral 
column,  as  is  familiar  to  every  csophagoscopist,  and  as  shown  graphically 
in  Fig.  42;'..  Zenker  recognized  the  effect  of  pressure  in  the  causation 
of  pulsion  diverticulum,  but  it  remained  for  Killian  to  demonstrate  the 
anatomically  weak  point  in  the  support  of  the  wall  and  the  spasmodic 
resistance  ahead  (jf  the  bolus.  Congenital  tliverticula  have  been  reported. 
It  might  be  supposed  th;it  an  esi)ecially  weak  wall  might  exist  from  birth 


0-12  msKASKs  or  run:  epoptiacus. 

were  it  not  for  the  fact  that  the  greatest  of  all  predisposing  factors  seems 
to  be  age.  Pressure  diverticula  are  never  seen  in  young  people,  very 
rarely  before  middle  life.  Possibly  crude  boluses  from  imperfect  masti- 
cation liy  defective  teeth  may  contribute,  but  considering  the  rarity  of 
diverticula  and  the  general  prevalence  of  imperfect  mastication  this 
alone  could  not  be  causative.  Sir  Felix  Semon  reports  a  very  interesting 
case  of  diverticulum  of  the  esophagus  occurring  in  conjunction  with  a 
cono-enitallv  deformed  larynx.     Undoubtedly  cicatricial  stenosis,  in  fact. 


Fig.  422. — Schema  illustrative  of  the  etiology  of  pressure  diverticula.  O, 
oblique  fibers  of  the  cricopharyngeus  attached  to  the  thyroid  cartilage,  T.  The 
fundi  form  fibers,  F,  encircle  the  mouth  of  the  esophagus.  Between  the  two  sets 
of  fibers  is  a  gap  in  the  support  of  the  esophageal  wall,  through  which  the  wall 
herniates  owing  to  the  pressure  of  food  propelled  by  the  oblique  fibers,  O,  ad- 
vance of  the  bolus  being  resisted  by  spasmodic  contraction  of  the  orbicular 
fibers,  F. 


any  sort  of  stenosis  below  the  level  of  the  inferior  constrictors,  may,  in 
rare  instances,  contribute  to  the  formation  of  a  diverticulum.  Some  of 
the  author's  cases  of  diverticulum  have  been  somewhat  cicatricial  at  the 
sub-diverticular  orifice.  This,  of  course,  in  a  long-standing  case,  might 
easily  have  resulted  from  erosion  and  ulceration  following  the  esopha- 
gitis  due  to  stagnation.  Undoubtedly  after  a  diverticulum  has  developed 
to  a  certain  degree  there  exists  "a  vicious  circle,"  that  is  the  food  in 
the  pendulous  portion  presses  on  the  sulxliverticular  portion  of  the 
esophagus   and   thus   increases  the   difticully   of   swallowing,   and   conse- 


DISITASKS  OF  TIIK  KSfilMI ACIS. 


543 


(liR-ntly  increases  stenosis,  with  consec|uent  increased  pressure  upon  the 
I)oucli.  I"rf)m  excessive  activity  the  ol)lii|uc  fibers  may  hypertrophy.  It 
is  thus  clear  that  all  that  is  needed  is  to  get  a  start;  later,  even  though 
the  causes  which  originally  started  the  trouble  should  disappear,  the 
diverticulum  will  perjietuate  itself  and  continue  to  increase  in  size.  (Fig. 
421  and  i-ir,). 

Proiinosis.  L'ntreated  pressure  diverticula  Ijecause  of  the  above 
mentioned  "vicious  circle"  probably  always  increase  steadily  in  size  and 
conse(|uently  in  distressing  symptoms.     This  is  shown  in  the  two  radio- 


FiG.  423. — Bismuth  radiograph  illustrating  normal  swallowing.  Tlie  bismuth 
mixture  is  seen  in  the  pyriform  sinuses,  D,  E.  .\t  A  and  C  is  seen  the  bismuth 
mixture  in  process  of  swallowing  while  the  cricoid  cartilage  is  in  close  contact 
with  the  posterior  pharyngoesophageal  wall. 


graphs  of  one  of  the  author's  patients  who  declined   operation.      (Figs. 
■I'^'l  and  A'2-)).    The  history  of  this  case  follows: 

Male,  aged  4()  years,  referred  to  the  author  by  Dr.  T.  \).  Uavis. 
Patient  stated  that  trouble  in  swallowing  and  spitting  u[)  of  food  began 
suddenly  after  he  "felt  something  give  way"  during  a  violent  attack  of 
coughing.  Cough  had  persisted  since.  Loss  of  weight  six  pounds. 
Esophagoscopy  showed  a  small  pouch  extending  outward  slightlv  to  the 
left.  The  cricopharyngeal  fold  was  quite  aciUch-  in  flanimator\-  anil  the 
pouch  showed  chronic  esophagitis.  The  subdixerticular  opening  was  a 
narrow  slit.  It  admitted  a  7  mm.  esojihagoscope  readily,  but  the  adult 
size    (111  mm.  I    lilted   \er\-   ti^btlv.     Chronic   larvngitis  was   manifest   but 


544 


DISEASES  OF  THE  ESOPHAGUS. 


laryngeal  motility  was  normal.  The  patient  declined  operation.  Four 
years  later  he  was  found  under  the  care  of  Dr.  Marks.  Operation  and 
esophagoscopy  were  both  declined  by  the  patient,  but  Dr.  Marks  very 
kindly  had  the  radiograph,  Fig.  425,  made  by  Dr.  George  C.  Johnston. 
The  prognosis  of  radical  operation  will  depend  partly  upon  the  condition 
of  the  patient.  If  feeble  from  malnutrition  and  advanced  age  the  prog- 
nosis is  more  grave  than  in  a  vigorous  person  of  middle  age.  Stettin 
collected  statistics  of  sixty  radically  operated  cases  with  ten  deaths  (in.G 


1 

H 

"1 

J 

Hi 

^^I^^^^^Bl 

ifl 

f  "^ 

HJ^ 

Hj 

i« 

--    ^^^^ 

1 

Iwl 

l^y-'^h   : 

^1 

m 

L. 

i^ 
^m 

^i^^^^l 

Fig.   424, — Pulsion   diverticulum   filled    with   bismuth    mixture    in   a   man    aged 
46  years.     (Radiographed  by  Dr.  Russell  H.  Boggs.     Author's  case.) 


per  cent).  As  the  duration  of  the  operation  is  lessened  by  one-half  by 
cso]ihagoscopic  aid,  the  mortality  in  the  future  will  be  diminished,  especi- 
ally in  the  aged  and  feeble. 

Symptoms.  The  chief  symptoms  are  cough,  regurgitation  of  food, 
gurgling  sound  and  subjective  sensation  on  swallowing,  a  peculiar  sour 
odor  to  the  breath,  and  difficulty  of  swallowing.  Boyce's  sign  can  usual- 
ly be  elicited  immediately  after  swallowing.  It  consists  in  a  gurgling 
sound  produced  by  pressure  of  the  hand  on  the  side  of  the  neck.  A  fresh 
swallowing  movement   without   food  or  water  is  needed   for  each  test. 


DISEASES  OF  THE  ESOPHAGUS. 


545 


The  sound  is  probabl)'  made  by  forcing  out  of  air  and  bubbles  of  secre- 
tion from  the  sac.  All  symptoms  are  valueless  diagnostically  but  they 
are  urgent  indications  for  esophagoscopy. 

Diagnosis.  A  radiograph  is  very  valuable  and  should  always  be 
made,  but  to  rely  upon  it  to  the  exclusion  of  esophagoscopy  is  to  take 
a  chance  of  serious  or  fatal  error  as  mentioned  in  connection  with  spas- 
modic and  organic  stenoses  and  malignancy.  (See  also  Fig.  41o.) 
X'arious  ijlind  methods  have  been  brought  forward,  with  a  great  deal  of 


Fig.  4J5. — Sana-  patiuiit  as  in  Fig.  .4.^4,  four  >Lar>  laKi,  llit-  patient  having  de- 
clined operation.  The  great  increase  in  size  is  usual  in  untreated  cases.  (Radio- 
.ttraph  made  by  Ilr.  George  C.  Johnston.    Author's  case.) 


enthusiasm,  for  the  diagnosis  of  esophageal  (li\  crliculuni.  They  are  very 
ingenious  and  would  be  perfectly  justifiable  in  the  days  when  esophago- 
sco])y  was  crude  or  unavailable.  It  is  hard  to  eradicate  traditions  in 
medicine,  and  te.xt  books  are  still  being  published  stating  that  the  tirsi 
step  i.i  the  diagnosis  of  diverticulum  is  to  pass  a  sound;  and  then  fol- 
low^ descriptions  of  various  other  blind  methods  in  groping  for  a  fre- 
quently erroneous  diagnosis.  These  are  all  wrong.  They  annoy  the 
liaticnt  and  ;ire  inconclusixe.  The  puiili>lied  statement  of  one  surgeon 
that  he  made  an  erroneous  diagnosis  of  carcinnm;i  of  tiie  esophagus  and 


546 


DISEASES  OF  THE  ESOPHAGUS. 


did  a  gastrostomy  in  a  case  of  diverticulum  in  wliicli  he  "decided  to  dis- 
pense with  the  esophagoscope  because  lie  (Hd  not  wish  to  subject  the 
patient  to  the  risk  and  great  annoyance"  leads  one  to  suppose  that  the 
surgeon  did  not  have  available  the  services  of  a  skilled  esophagoscopist, 
or  possibly  he  had  only  seen  the  crude  work  of  the  earlv  davs.  There  is 
neither  risk  nor  great  annoyance  connected  with  modern  esophagoscopv. 
The  first  step  in  the  diagnosis  should  be  a  radiograph  and  the  next  step 
should  be  esophagoscopy.  The  diagnosis  will  then  be  made  positively 
or  negatively  with  a  certainty  that  will  render  further  diagnostic  pro- 
cedures  superfluous.      As   a   large   quantity   of   bismuth    is    required    for 


^ 


Fig.  426. — The  author's  esophagoscope  with  slanted  end,  facilitating  introduc- 
tion in  any  case  and  especially  useful  in  entering  the  subdiverticular  opening  in 
cases  of  diverticulum.  The  drainage  canal  facilitates  aspiration  of  secretions 
without  interruption  of  the  work.  Though  similar  to  the  bronchoscope,  this  esoph- 
agoscope differs  in  having  no  lateral  openings,  and  in  the  liranch  tube  entering 
an  auxiliary  drainage  canal  ending  at  the  tube  mouth,  like  the  regular  esophago- 
scope which  it  has  superseded.     The  lip  is  also    useful  in  foreign  body  work. 


radiography  of  a  large  diverticulum  or  in  the  case  of  dilatation  bismuth 
subcarbonate  should  always  be  used  rather  than  the  subnitrate.  Zir- 
conium oxide,  though  somewhat  expensive,  is  strictly  non  poisonous. 
As  pointed  out  by  Kahler.  if  there  is  reason  to  suspect  a  tracheoesopha- 
geal fistula  the  swallowing  of  bismuch  emulsion  had  better  be  avoided. 
In  one  such  case  a  radiographic  picture  was  obtained  of  the  entire 
tracheobronchial  tree  filled  with  liismuth  which  had  found  its  wav  in 
through  such  a  fistula.  Malignant,  sjiasmodic.  cicatricial  and  compres- 
sive stenoses  are  to  be  excluded  by  the  esojihagoscojiic  ai)])earances 
Aneurysm  is  to  be  excluded  by  radiography  and  fluoroscoi)y. 

Esophagoscopy   in   cases   of  suspected   dkuvticuluiii.      L'ntil   a   num- 
ber'of  cases  have  been  exjjlored  the  esophagoscopist  will  find  some  difh- 


DISKASES  01'  THK  ESOCIIACIS. 


547 


cull}'  in  Ideating  the  siili(livi.Tticf:lar  esophageal  ojiening.  The  insertion 
of  the  tube  into  the  pouch  is  usually  very  easy.  Its  running  into  a  blind 
end  or  sort  of  pocket  beyond  which  it  will  not  go.  and  in  the  bottom  of 
which  there  is  no  opening,  is  almost  diagnostic  of  pressure  diverticulum. 
If  in  addition  to  this  on  withdrawing  the  esophagoscope  a  little  distance, 
we  are  able  to  find  on  the  anterior  wall,  a  narrow'ed.  usuallv  slit-like 
opening  into  the  lower  esophagus,  and  we  are  able  to  enter  this  opening 
with  either  a  very  small  tube  or  a  jirobe.  which  passes  down  readily, 
the  diagnosis  is  absolute.  The  author  uses  the  slanted-end  esophago- 
scope (Fig.  I2<i)  to  enter  this  slit  and  exjjlore  the  subdivertieular  esoph- 
agus.    True  malignancy  may  exist  below,  and  this  the  author  has  seen 


Fu..  4->7. — Esuphagoscopic  \icws  in  cases  of  ilivertii'uluin.  I'atient  rccuiiibciU. 
.-\,  endoscopic  view  of  linear  suture  after  amptitaticni  of  tlu'  divcrticiihim.  P>, 
after  suture  by  li;jation  and  Iransfixation  in  another  case,  (.'rayon  drawings  by 
the  author,  after  operation  by  Dr.  Otto  C.  Gaub.  C,  view  looking  into  pouch 
after  partial  withdrawal  of  the  esophagoscope  in  a  man  aged  6-  years.  .Slit-like 
f)rifiee  of  subdivertieular  esophagus  seen  in  upper  right  quadrant.  1),  view  of 
diverticular  nrilice  in  case  of  a  woman  of  58  years  of  age.  Subdivertieular  orifice 
overhung  by  a  fold  in  upper  left  quadrant.  The  ledge  between  the  orifice  and  the 
diverticular  opening,  supported  by  the  orbicular  fibers  of  the  cricopharyngeus,  is 
cicatricial. 


in  one  case,  though,  m  liis  opniion,  the  <le\elopmenl  of  nialignanev  was 
secondary  to  the  di\erticulum  ;inil  to  the  subse(|ui'nt  pathologic  changes; 
because  (jrdinarily  malignancy  does  not  last  sutliciently  long  for  a  divertic- 
ulum to  dcvclo])  from  malignant  stenosis.  It  is  quite  characteristic  of 
high  (li\-ertietil;i  due  to  pressure  th;it  the  pouch  seems  to  be  the  continu- 
ation of  the  pharynx,  and  it  is  only  with  the  most  minute  care  and  skill- 
ful work  that  the  subdi\ertictilar  ojiening  can  be  found,  (lireat  care  must 
be  used  not  to  jierforate  the  bottom  of  the  pouch  and  not  to  tise  an\-  pres- 
sure upon  it.  \\  hen  the  esophagoscopist  tinds  that  the  lube  has  entered 
a  blind  c;i\ity  ;ind  cannot  be  introduced  ftirther,  he  shottld  withdraw  the 
ttilie  while  keeping  :i  close  w.atcli  on  the  aiUerior  wall.  Careful  search 
on   this   wall   will   dis-.-oxer  .-m   opening,   somctiiues   slit-like    (C.   1),    Fig. 


548  DISEASES  OF  THE  ESOPHAGUS. 

427)    sometimes  very  small,   rarely  stellate,  and  very   frequently   over- 
hung by  a  somewhat  projecting  fold.    Some  esophagoscopists  have  failed 
to  find  the  opening  and  have  advised  the  swallowing  of  a  thread  with 
which  to  guide  the  esophagoscope.     Such  an  expedient  is  quite  unneces- 
sary though  there  is  no  objection  to  its  use  other  than  the  delay  and  the 
annoyance  for  twenty-four  hours  or  longer  when,   instead,   but  a   few 
minutes  of  esophagoscopy  should   suffice.     The   subdiverticular  opening 
is  apt  to  gape  during  swallowing.     Therefore,  it  is  often  advantageous 
to  get  the  patient  to  make  the  swallowing  movement  if  he  can.     This  is 
one  of  the    advantages    in    making    the    examination    without    general 
anesthesia.     The  best  way  of   conducting  these  examinations  is  to  use 
the  esophageal  speculum  Fig.  21,  and    after    having    discovered    what 
seems  to  be  the  cleft,  to'insert  a  child's  size  of  the  esophagoscope  with  a 
slanted  end.  Fig.  426,  through  the  speculum.    When  it  is  certain  that  we 
really  have  discovered  the  subdiverticular  opening,  the  slanted-end  esoph- 
agoscope  can    usually    be   entered    without    difhculty    and    without    the 
speculum,  provided  there  is  no  stricture.     If  there  is  a  stricture,  it  should 
be  divulsed  with  one  of  the  divulsors  previously  mentioned,  or  an  adult 
esophagoscope   (Fig.  426)   can  be  forced  into  it,  using  the  slanted  end 
as   an  entering  wedge.     The  square-ended   esophagoscope,   which   is   so 
safe  and  popular  for  general  use,  is  here  at  a  disadvantage  because  of 
the   difticulty   of   insertion   into   the   cleft-like   orifice   along   the   anterior 
wall  of  the  orifice  of  the  diverticulum.     One  would  suppose   from  the 
name  diverticulum,   that  in  passing    down    the    esophagus    one    would 
notice  a  little  side  opening  leading  off  into  the  pouch.    This,  however,  is 
far  from  the  case.     Usually  in  pharyngeal  diverticulum,  the  whole  hypo- 
pharynx  ends  in  a  blind  sac.     The  upper  orifice  of  the  diverticulum  is 
seemingly   just    simply    the   entire    pharynx.      The    subdiverticular   eso- 
phageal opening,  on  the  contrary',  is  a  minute  cleft  up  above  the  bottom 
of  the  diverticulum,  ami  usually  on  the  anterior  wall  of  the  diverticulum, 
often  close  against  the  cricoid  cartilage.     The  ledge  between  the  orifice 
of  the  diverticulum  and  the  subdiverticular  orifice  of  the  esophagus  is 
supported  by  the  orbicular  fibers  of  the  cricopharyngeus   (often  hyper- 
troi)hicdi,   whose   contraction  ahead   of   the   downward   propelled  bolus 
has  been   the  ])rime   factor  in   the  production  of  the  hernia  known   as 
diverticulum.     It  is  not  so  much  this  ledge  that  interferes  with  exposing 
the  subdiverticular  orifice  as  it  is  the  pressure  of  the  cricoid  cartilage 
which  pushes  the  esophagoscope  backward  and  outward  into  the  large 
and  unobstructed  diverticular  orifice.     It  requires  firm  anterior  pressure 
with  the  tube  mouth  to  expose  any  orifice  of  the  subdiverticular  lumen 
and  then  it  will  be  found  to  he  the  merest  slit  and  not  a  gaping  orifice. 


DISEASES  OF  TUIC  l"Si )!' II  ACUS. 


549 


In  the  very  early  stages  of  diverticulum,  there  is  sometimes  not  a  true 
pouch.  In  such  instances,  the  subdiverlicular  opening  is  easy  to  find. 
The  color  of  the  mucosa  lining  a  diverticulum  may  be  reddish  or  it  may 
be  macerated  with  a  grayish  color  almost  resembling  an  exudate.  That 
it  is  not  a  true  exudate  is  manifest  by  the  impossibility  of  removing  it, 
and  it  seems  to  be  simjjly  macerated  epithelial  cells  furred  up  but  not 
detached.  In  other  cases  the  diverticulum  is  rather  paler  than  usual 
and  there  being  no  pasty  exudate  on  the  surface,  minute  vessels  are 
plainlv  visible  in  everv  direction.  There  may  be  superficial  erosions 
and  patches  of  inflammation.  Cicatrices  were  noted  by  the  author  in  one 
case.     The   depth   of  a   pulsion   ili\erticulum   may   be   from   one  to   ten 


Fit;.  428. — Bi'ginnini;  recurrence  of  esophageal  ilivcrticuhim  in  a  man  aged  5.i 
years,  witliin  a  year  after  removal  by  a  very  skillful  surgeon. 


centimeters,  though  usually  they  are  not  over  1  centimeters  in  deiilh,  as 
determined  esophagoscopicall) ,  which  nuaus  in  a  more  or  less  collapsed 
state.  When  full  of  food,  they  are,  of  course,  dilated  to  a  very  much 
greater  extent.  In  one  of  the  author's  cases  the  diverticulum  filled  with 
air  every  time  the  patient  swallowed  without  food  or  drink.  Its  normal 
state  seemed  to  be  air  dilatation.  The  same  con<lition  was  suspected  in 
other  cases  but  not  proven. 

Recurrence  of  esophageal  dh  crticidiim  after  operation.  I'ulsiou 
diverticulum  has  been  known  to  recur  after  thorough  removal  by  the 
most  skilful  surgeons;  and  surgeons  who  have  no  record  of  recurrences 
possibly  have  not  had  ojjportunities  of  following  their  cases.  In  a  case 
esophagoscoped    for   the  exclusion   of   malignancy   hy   llie   .lUlhor   in   con- 


550  DISEASES  OF  THE  ESOPHAGUS. 

sultation  with  Dr.  George  \\'.  Crile  and  Dr.  George  E.  I'.rewer  there 
was  a  large  diverticukim  which  had  formed  during  the  twelve  years  fol- 
lowing a  resection  of  the  first  diverticulum  by  Dr.  .Morris  Richardson, 
whose  operation  was,  of  course,  thorough  and  complete,  and  had  given 
perfect  relief  for  years.  The  recurrence  brought  back  all  of  the  old 
svmptoms.  The  patient  recovered  absolutely  normal  swallowing  after  a 
verv  skilful  operation  by  Dr.  Crile,  and  now,  at  the  end  of  four  years. 
is  swallowing  normally  without  signs  of  recurrence. 

Recurrences  are  doubtless  due  to  the  same  causes  as  produced  the 
original  diverticulum.  The  author  has  thought  that,  as  the  original  cause 
is  the  weak  point  in  the  support  of  the  esophageal  wall,  a  leakage  after 
operation,  with  conse(|uent  localized  inflammation,  far  from  being  un- 
desirable, might  Ije  a  great  advantage  in  bulwarking  the  weakly  supported 
area  of  the  wall,  which  is  necessarily  right  at  the  point  of  amputation 
of  the  sac.  As  yet,  the  number  of  cases  that  have  been  followed  have 
been  too  small  to  yield  any  data.  One  case  observed  by  the  author  tends 
to  confirm  this  theoretical  conclusion.  Figure  428  shows  a  beginning 
recurrence  within  a  year  after  thorough  removal  by  a  very  skilful 
surgeon.     There  was  no  leakage  after  the  operation. 

Treatment  of  pulsion  diverticulum.  Xo  endoscopic  treatment  is  of 
any  avail  in  esophageal  diverticulum,  so  far  as  the  removal  of  redundancy 
is  concerned.  If  the  diverticulum  is  very  small,  the  lower  opening  may 
be  freely  dilated.  This  accomplished  a  cure  in  one  case  of  the  author, 
but  the  diverticulum  was  \ery  small.  There  was  no  organic  stricture, 
only  spastic  stenosis  In  another  case  the  subdiverticular  orifice  was 
small  and  cicatricial.  Divulsion  resulted  in  relief  of  the  svmptoms,  liut 
the  diverticulum  remained.  Both  cases  had  refused  external  operation. 
W  hen  there  's  an\-  degree  of  redundancy  present,  in  the  author's  opinion, 
it  is  very  much  better  to  have  an  external  operation  done  by  the  gen- 
eral surgeon.  The  author  has  devised  an  operation  where,  by  the  use 
of  the  esophageal  speculum.  Fig.  21,  the  bottom  of  the  sac  mav  be 
grasped  by  forceps  and  drawn  in.  encircled  by  a  ligature  and  the  end  cut 
off  and  sealed  over  with  a  touch  of  tincture  of  iodine,  about  half  strength. 
As  yet  no  suitable  case  for  this  operation  has  come  under  the  author's 
observation.  Glottic  spasm  resulted  every  time  traction  was  made,  in  the 
two  cases  tested.  In  the  event  of  radical  operation  being  contra- 
indicated  because  of  advanced  age  or  of  organic  disease  present  in 
quite  a  proportion  of  cases,  the  best  palliative  treatment  is  to  keep  down 
the  chronic  inflammatory  state  by  preventing  the  entrance  of  food,  or 
by  evacuating  and  cleansing  the  sac.  The  best  method  of  doing  this  is 
that  of  Starck  as  follows: 


DISI'ASI-S  OI-   TJin  KSOIMlACrS. 


•ll 


■■'I'lio  aim  .-liDulil  lie  to  prevonl  food  from  Ljfttiny  into  the  diverti- 
culum, and,  if  it  does,  to  clear  it  out.  Tiiis  can  sometimes  be  accom- 
plished by  reclining  in  a  certain  position,  by  stooping  over  or  by  jiressure 
on  the  throat  from  without  or  other  maneuver.  This  should  be  studied 
until  some  measure  is  found  which  will  relieve.  If  nothing  of  the  kind 
can  be  discovered,  then  the  diverticulum  tube  must  be  used.  It  may  be 
nccessarv  during  the  meal,  as  the  filling  of  the  diverticulum  mav  com- 


Fic.  ^2g. — .Scluiiialic  rcpreseiitatici!  of  csoplia^oscopic  aid  in  tlu'  excision  of 
a  diverticulum.  At  .\  the  es.ophagoscope  is  represented  in  the  hottom  of  the 
pouch,  after  the  surgeon  has  cut  down  to  where  he  can  feel  the  csophagoscope. 
Then  the  csophagoscopist  causes  the  pouch  to  protrude  as  shown  by  the  dotted 
line  al  F^,.  .After  the  surgeon  lias  dissected  the  sack  entirely  loose  from  its  sur- 
roun(lin;,'s,  traction  is  made  upon  the  sack  as  shown  at  H  and  the  csophagoscope  is 
inserted  down  the  lumen  of  tlie  csopl'.agus  as  shown  at  C.  The  csophagoscope 
now  occupies  the  lumen  which  the  patient  will  need  for  swallowing.  It  only  re- 
mains for  the  surgeon  to  remove  the  redimdaucy,  without  risk  of  removing  any 
of  the  normal  wall. 


press  the  esophagus  so  that  its  lumen  is  olistructed  ;  in  any  e\eni  tlic 
toilet  of  the  (li\erticiilum  should  follow  the  meal.  .Xearlv  ever\'  patient 
has  his  own  method  of  eating  to  i)revenl  annoyance  from  the  food  get- 
ting into  the  cli\t-rticnlum  ;  oik-  can  swallow  bclU-r  when  he  looks  at  the 
ceiling,  another  when  he  bends  his  head  to  the  right  or  left,  another  as 
he  stoops  his  body  forward,  or  ])resses  "U  the  tr.aclu'a  from  the  front 
or  the  side  or   from  behii'd   ihe  sternocleidomastoid   muscle.      Xeukirch 


553  DISEASES  OF  THE  ESOPHAGUS. 

had  a  patient  who  could  swallow  best  when  he  reclined,  lying  on  his 
right  side.  The  various  postures  should  be  tried  until  the  one  giving 
the  most  relief  is  discovered." 

The  excision  of  a  diverticulum  in  the  neck,  one  would  suppose  from 
the  description  in  the  text  hooks  to  be  an  exceedingly  easy  procedure,  and 
so  it  may  be  in  the  case  of  a  large  diverticulum  in  an  emaciated  long- 
necked  person.  On  the  contrary  with  a  short  thick-necked  individual  and 
a  small  diverticulum,  it  may  be  exceedingly  difficult ;  so  much  so  that  it 
has  happened  to  a  number  of  very  competent  surgeons  that  after  the 
operation  the  diverticulum  remained  as  before.  If  a  diverticulum  at  oper- 
ation were  full  of  a  solid  as  it  is  when  the  radiograph  is  taken,  finding  it 
would  be  easy,  but  the  sac  is  extremely  elastic  and  when  empty,  as  it 
must  be  for  operation,  it  shrinks  up  to  small  dimensions.  It  lies  back  of, 
or  close  alongside  the  esophagus,  and  may  be  indistinguishable  from  a 
fold  of  the  esophageal  wall,  and  it  may  be  on  the  opposite  side  of  the  neck 
at  the  time  it  is  sought.  Free  dissection  of  the  esophagus  clear  from  all 
surrounding  structures  and  bringing  it  out  for  examination  as  one  would 
an  intestine  is,  of  course,  impossible.  All  of  these  considerations  render 
the  operation  as  ordinarily  done  a  lengthy  and  a  tedious  one  that  is 
quite  an  ordeai  for  old  debilitated  patients.  The  duration  of  the  opera- 
tion is  lessened  by  a  half  or  two- thirds  and  the  difficulties  for  the  sur- 
geon are  greatlv  diminished  if  he  have  the  cooperation  of  an  esophagos- 
copist  as  originally  proposed  by  Dr.  Otto  C.  Gaub.  A  description  of 
the  esophagoscopist's  part  of  Dr.  Gaub's  operation  is  all  that  is  within 
the  province  of  this  book.  This  will  be  fully  understood  by  reference 
to  the  schema.  Fig.  429.  In  these  operations  it  is,  of  course,  absolutely 
necessary  that  the  surgeon  have  his  sterile  tables,  nurses  and  assistants 
entirely  independent  of  the  esophagoscopist  who  has  his  sterile  organiza- 
tion at  the  head  of  the  table  with  the  anesthetist.  Two  cases  in  which 
the  author  thus  assisted  Dr.  Gaub  may  be  cited. 

Airs.  D.,  aged  58  years,  referred  by  Dr.  R.  W.  Fisher,  for  increasing 
difficulty  in  swallowing  solids.  Foul  breath  and  a  cough  were  annoying 
at  times.  Had  "ulcerated  sore  throat"  four  years  before.  Swallowing 
symptoms  were  of  one  year's  duration.  No  regurgitation.  Examination 
with  the  esophageal  speculum  (Fig.  21),  without  anesthesia,  general  or 
local,  showed  a  small  diverticulum  to  the  left  side.  Withdrawal  re- 
vealed the  orifice  of  the  subdiverticular  esophagus  anteriorly  to  the  right 
covered  with  a  fold.  The  ridge  between  this  orifice  and  the  diverticular 
orifice  was  cicatricial  (D,  Fig.  427).  The  subdiverticular  orifice  was 
easily  entered  with  the  beak  of  the  slanted-end  esophagoscope  (Fig  42G) 
but  would  not  permit  the  entire  end  to  enter  readily.  Enough  pressure 
was  used  to  stretch  the  cicatricially  contracted  orifice  and  permit  the 


DISEASES  OF  TUU  E^OPllAGLS. 


553 


esophagoscope  to  enter  freely.  At  esophagoscopy,  seventeen  days  later, 
without  anesthesia,  the  esophagoscope  entered  readily  without  any  sign 
of  recurrence  of  stenosis.  Radiography  by  Dr.  George  C.  Johnston 
showed  the  diverticulum  (Fig.  430).  External  operation  was  quickly 
and  skillfully  done  by  the  Otto  C.  Gaub  method  in  which  the  esophagos- 
copist  with  esophagoscope  inserted  through  the  mouth  into  the  bottom 
of  the  pouch  presents  the  sac  in  the  wound  to  the  surgeon  after  the  lat- 
ter has  dissected  externally  down  to  the  esophagus    (Fig.  429).     After 


Fig.  4,30. — Radiograpli  li\  Hr.  Gcorgt-  C.  Johnston  showing  divorticnhnn  in 
case  of  a  woman,  aged  58  years.  Uivcrticnlnni  rifterwanls  rcmcjvcd  by  the  OUo  C. 
Gaulj  method. 


Dr.  Gaul)  had  laid  bare  the  esophagus  by  external  dissection  he  asked 
the  author  to  insert  the  esophagoscope  and  present  the  pouch  in  the 
wound.  When  Dr.  Gaub  had  seized  the  bottom  of  the  sac  with  forceps 
and  made  traction  the  esophagoscope  was  withdrawn  to  the  hypopharynx 
and  the  orifice  of  the  diverticulum  disappeared  while  the  subdiverticular 
orifice  opened  up  ahead  of  the  tube-mouth  in  full  lumen.  Inserting  the 
esophagoscope  in  this  lumen  as  far  as  the  crossing  of  the  left  bronchus 
the  surgeon  amjiutatcd  the  redundancy  while  the  esophagoscope  indi- 
cated the  normal  liunen.    The  neck  of  the  sac  was  ligated  and  transfixed. 


554 


niSKASI'S  OF  THE  ESOPHAGUS. 


When  the  esophagoscope  was  withdrawn  a  neat  puckered  spot  of  suture 
was  seen  by  the  author  who  made  the  sketch,  B,  Fig.  4'27.  The  stump 
externally  was  lightlv  touched  with  pure  carbolic  acid,  and  supporting 
sutures  were  used.  Feeding  was  by  catheter  inserted  at  esophagoscopy. 
Primary  union  and  prompt  recovery  followed,  and  one  year  later  the 
patient  was   still   swallowing  perfectly. 

Remarks.      In   this  case  Dr.   (laub  made  traction  on  the  bottom  of 
the  sac  with  forceps  and  the  author  withdrew  his  esophagoscope  to  the 


Fig.  431. — Radiograph  by  Dr.  Pancoast  of  Philadelphia,  showing  a  diverticulum 
in  a  man  of  6-  years.     Diverticulum  removed  by  the  Otto  C.  Gaub  method. 


h_\  popliar\n.\  and  noted  that  the  traction  Ijv  Dr.  ("laub  caused  the  sub- 
diverticular  esophagus  to  gape  widely,  bringing  it  into  a  straight  line 
with  tile  esophagus  below.  This  manipulation  demonstrated  clearly  that 
the  dilticulties  in  swallowing  and  in  finding  the  subdixerticular  orifice  at 
diagnostic  esophagcscopy  are  largely  concerned  with  the  pouch  and  its 
position,  and  not  alone  with  tlie  spasm  of  the  orbicular  fibers  of  the 
cricopharyngeus. 

Mr.  F.,  aged  (u   years,  was  referred  by  Dr.  r)a\id  Riesman  and  Dr. 
Walter  J.   Freeman  of  f'liiladelphia.      The\-   had   made  the  diagnosis  of 


UISICAsns  Ol-    I'lII-.  ESUl'HAC.US.  o')') 

(livcriiculuni.  Severe  (.•nu^h,  piinileiu  expectoration  aiul  (litliciilty  in 
swallowing  hail  made  the  patient's  life  miserable  for  the  past  year.  Re- 
gurgitation and  loul  hreath  had  been  noticed  for  six  months.  Examina- 
tion with  the  esophageal  speculum,  using  a  little  8  percent  cocaine  solu- 
tion tn  tin-  larvngo])harynx,  showed  a  large  pouch  confirming  the  radio- 
gra[)h  by  Dr.  ilenry  K.  I'ancoast,  J'ig.  -I'il.  The  subdiverticular  orifice 
( C,  Fig.  427 )  was  easily  entered  with  the  slanted-end  esophagoscope, 
Fig.  •!?(>.  There  were  no  signs  of  cicatrices  or  inflammatory  processes. 
The  orifice  of  the  pouch  just  as  the  esophagoscope  emerged  from  it  was 
circular  in  outline  and  rolled  o\er  at  the  margins  (  C,  Fig.  127).  The 
Gaub  operation  with  esophagoscopic  aid  was  done  by  Dr.  Gaub.  the 
steps  being  the  same  as  in  the  preceding  case,  and  the  same  observation 


Fii;.  4_3J. — Pulsion   (livcrticuluni  cf  tlie  esophagus  removed   from   a   man   aged 
()-  years,  by  Dr.  Otto  C.  Ganb. 


as  to  opening  u|>  of  the  subdiverticular  esophageal  lumen  was  made 
as  in  the  preceding  case.  The  pouch  after  removal  is  .shown  in  iMg.  1  :>"■.'. 
'i'lie  recovery  was  rather  tedious.  Leakage  of  about  one-third  of  swal- 
liiucd  li(|uiils  gradually  inii)roved  as  the  fistula  closed.  Healing  was 
complete  and  swallowing  perfect  in  about  four  weeks,  the  patient  reliu-n- 
ing  to  I'hil.-idelpiiia  six  weeks  after  operation. 

J^riiHirks.  'j'his  patient  was  regarded  by  Dr.  j.  .M .  McKelvy  before 
ojieration  as  an  unfavorable  surgical  subject  because  of  feebleness,  ad- 
vanced age.  impaired  vessels,  and  chronic  jiurulent  bronchitis.  The 
post  operative  condition  \erified  the  opiifion  ;  and  it  was  onl\  b\  the  at- 
tentive after  care  of  Dr.  Gaub  and  Dr.  McKelvy  that  the  jiatient  made 
sucii  an  excellent  recovery.  Intratracheal  insulllation  anesthesia  with 
the  Elsberg  api>aratus  was  used  in  both  the  foregoing  cases.  The  in- 
sulllation  method   not    only    removes   the   anesthelist    from   liie   (]|)er,-itor's 


556  DISEASES  OF  THE  ESOPHAGUS. 

way,  and  avoids  infective  risks,  but  also  insures  safety  of  respiration 
and  a  quiet  peaceful  anesthesia,  in  spite  of  tracheal  pressure  from  the 
esophagoscope  or  glottic  spasm  from  the  surgeon's  dissection. 

After-care.  As  the  primary  cause  of  the  diverticulum  was  high 
pressure  of  swallowed  food  and  drink  held  back  by  the  spasm  of  the 
orbicular  fibers  of  the  cricopharyngeus  at  the  bottom  of  the  hypopharynx, 
naturally  it  follows  that  swallowing  will  put  great  strain  on  the  stitches. 
For  this  reason  it  is  wise  to  place  a  feeding  catheter  of  small  size  in  the 
esophagus  at  the  time  of  operation,  preferably  through  the  esophageal 
speculum.  If  put  in  afterward  it  may  catch  at  the  point  of  suture. 
Should  leakage  start  and  the  leakage  through  the  neck  wound  be  so 
great  that  enough  food  and  water  do  not  reach  the  stomach,  fluid  food 
can  be  carried  safely  past  the  wound  by  feeding  through  the  catheter. 
If  this  be  done  an  abundance  of  sterile  water  must  he  drunk  in  addition 
in  order  to  flush  out  the  wound.  Usually  by  this  time  granulations  af- 
ford some  protection  against  serious  infection  and  the  channels  to  the 
mediastinum  are  sealed.  The  wotind,  in  case  of  leakage,  is  already  in- 
fected with  the  esophageal  and  buccal  organisms,  but  to  these  the 
patient  is  more  or  less  immune.  The  water  must  be  sterile  to  insure 
exclusion  of  virulent  infections  from  without.  If  offensive  odor  develops, 
frequent  irrigation  by  swallowing  sterile  water  will  quickly  cause  it  to 
disappear.  j\Ir.  Walter  Howarth  made  the  excellent  suggestion,  apropos 
of  the  case  of  Mr.  F.,  that  hydrogen  peroxid  be  added  to  the  water. 
In  order  to  determine  the  amount  of  fluid  that  goes  into  the  stomach, 
the  method  of  Dr.  Otto  C.  Gaub  is  useful.  When  the  patient  swallows 
water  the  leakage  is  caught  in  a  curved  pan  held  at  the  external  wouml, 
and  the  quantity  is  measured.  Subtraction  of  this  from  the  total  (|uan- 
tity  swallowed  necessarily  gives  the  amount  that  went  to  the  stomach. 
As  oral  sepsis  is  one  of  the  greatest  dangers,  cleanliness  of  the  mouth 
must  be  insured  by  brushing  the  teeth  every  few  hours,  and  by  the  rins- 
ing of  the  mouth  with  alcohol  1  part  to  5  of  water.  After  operation 
it  is  wise  for  the  surgeon  to  have  a  bismuth  radiograph  taken  and  to 
have  an  esophagoscopy,  both  as  a  matter  of  record  and  to  make  sure  that 
even,-thing  is  anatomically  as  well  as  functionally  normal  in  the  esophagus. 


CHAPTER     XXXIV. 

Diseases  of  the  Esophagus.     Continued. 

r.\KALYSIS  OF  Tllli   ESOPHAGUS. 

Paralysis  of  the  csophui/iLs  may  be  motor  or  sensory. — Motor 
paralysis  of  the  esophagus  is  perhaps  more  frequently  seen  as  a 
glosso-labio-pharyns^eal  paralysis  of  either  toxic  origin  as  in  diph- 
theria, or  of  central  origin.  In  any  case,  swallowing  is  apt  to  be  seriously 
interfered  with,  and,  strange  to  say,  esophageal  drainage  is  interfered 
with  also.  This  is  manifest  by  the  filling  of  the  pyriform  sinuses  with 
secretion  (author's  sign  of  esophageal  stenosis)  until  the  secretion  over- 
flows into  the  larynx,  just  as  in  an  esophagus  occluded  l)y  cancer  or 
organic  stricture.  This  is  apjiarent  on  indirect  as  well  as  direct  examina- 
tion. It  is  a  remarkable  thing  that  though  the  normal  esophagus  can  swal- 
low "up  hill"  with  ease,  food,  either  li<|uid  or  solid,  will  not  go  down  the 
paralyzed  esophagus  Ijy  gravity  alone.  The  act  of  deglutition  is  a  i)urely 
muscular  process  and  the  food  is  forced  down  by  coordinate  muscular 
activity.  Xormally  the  esophagus  empties  itself  promptly  of  everything 
which  is  put  into  it.  It  abhors  the  presence  of  anything  except  secre- 
tions, and  even  secretions  are  promptly  gotten  rid  of  in  a  state  of  health. 
Phylogenctically,  the  erect  posture  was  developed  late,  therefore,  there 
has  been  no  opportunity  for  the  develo])ment  of  deglutition  with  the 
assistance  of  gravity.  Muscular  action  is  depended  upon  entirely. 
Therefore,  it  is  well  to  mention  here  again  what  was  stated  in  the  first 
volume  (Bib.  2ii9)  :  namely,  that  the  first  symi)tom  of  paralysis  or  paresis 
of  the  esojihagus  is  inability  to  swallow.  That  paralysis  of  soisation 
in  the  esoi)hagus  may  result  in  inaliility  to  swallow  because  of  the  lack 
of  tile  necessary  serial  reflex  impulse  is  proven  Ijy  the  following  case 
refcTred  to  tlie  author  for  esophagoscopy  by  Drs.  li.  V>.  llowarth  and 
Kobert  Milligan.  A  man  of  forty-eight  years  had  difficulty  in  swallow- 
ing  for  eight  weeks,  culminating  in  absolute   inabilitv   to  swallow.     On 


558  DISEASES  OF  Till-:  ICSUI'MACUS. 

indirect  laryngoscopy  laryngeal  motility  was  found  to  be  perfect.  The 
pyriform  sinuses  were  full  of  secretion.  A  bronchoscope  was  passed  to 
the  bifurcation  of  the  trachea  without  anesthesia,  general  or  local,  and 
there  was  not  the  slightest  sign  of  a  cough  reflex.  Esophagoscopy 
showed  ])resence  of  cricojiharyngeal  and  hiatal  contractions,  though  very 
weak  and  unlike  normal  spasmodic  resistance  to  the  achance  of  the 
esophagoscope.  A  lo  mm.  x  5:i  cm.  esophagoscope  passed  readilv  into 
the  stomach.  There  was  no  gagging,  retching  or  attempted  vomiting. 
The  author  made  a  diagnosis  of  sensory  paralysis,  with  consequent  ab- 
sence of  the  normal  serial  deglutitory  reflex,  and  turned  the  case  over 
to  Dr.  C.  C.  Wholey  for  neurologic  analysis  and  treatment.  The  follow- 
ing is  Dr.  Wholey's  report : 

"Patient's  mental  condition  is  good,  but  he  shows  some  anxiety  re- 
garding his  condition.  There  is  noticeable  dilatation  of  the  venules  over 
cheeks.  E.  J.'s  (biceps  i_  \\'.  J.'s.  and  muscle  tap  (biceps)  all  plus  and 
eciual  on  both  sides.  K.  J.'s  (taken  in  bed)  absen.t — also  absent  when 
sitting.  I'lantars  lively.  No  Babinski.  No  Oppenheim,  Tongue  pro- 
trudes slightly  to  the  left.  Eyes.  Pupils — Rt. — i  x  4,  irregular  (wider 
below.)  Lft.  3J/  X  3J,-2,  irregular  (wider  above).  Both  inipils  react 
l)romptly  to  light  with  fair  excursion;  both  react  to  accommodation. 
Patient  shows  slight  Rhombergism;  is  able  to  pucker  lips  and  protrude 
tongue.  Abdominal  reflex  absent.  Cremasteric  present  but  slow  in  re- 
sponse. Sensation  :  Patient's  sensation  to  touch,  heat  and  cold  normal 
over  entire  body,  but  sensation  for  pain  is  diminished  from  the  hips 
to  soles  of  feet.  Increasing  analgesia  as  soles  of  feet  are  approached, 
being  very  marked  in  soles  of  feet.  For  tlie  last  one  and  a  half  to  two 
years  patient  has  complained  of  sensation  of  pins  and  needles  in  thighs, 
of  impairment  of  the  sense  of  taste,  of  anorexia  from  time  to  time  dur- 
ing the  past  few  month.s,  and  obstinate  constipation  (loss  of  sensation 
in  rectum).  Desire  has  been  present,  but  patient  has  been  impotent 
sexually  during  the  past  IJ,^  years.  Patient  says  he  has  been  unaware 
of  any  desire  to  urinate  or  to  defecate  during  the  past  month  ;  simply  goes 
mechanically.  Patient  coughs  a  great  deal,  brings  up  thick  mucous,  but 
his  expelling  ])ower  seemed  to  be  largelv  from  the  diaphragm  and  ab- 
dominal muscles.  Examination  of  urine  is  negative,  except  for  the  pres- 
ence of  a  reducing  agent  present  in  small  amount  and  found  to  be  glu- 
cose. No  T.  ]!.  found  in  sputum,  i'.lood  picture  is  negative,  except  for 
very  slight  leucocytosis.  ^^■assermann  negative.  The  spinal  fluid  shows 
-"iK'  lymi)hocytes  per  cmm.  ("dobulin  positive,  ^\'assermann  negative. 
Radiographer  after  examination  of  lumbar  region  reports  osteo-arthritis 
of  vertebrae.  Radiograms  of  lumbar  and  cervical  regions  show  numerous 
small  si)icules  projecting  from  bodies,  and  lateral  processes  of  vertebrae. 


DisKAsKs  cj"  rill-:  i:sui'iiacus.  .").".!) 

During  the  week  subsequent  to  above  examination,  patient  had  several 
periods  during  which  he  developed  Cheyne-Stokes  respiration,  and 
seemed  in  imminent  danger  of  dying.  .Mercurial  inunctions  have  been 
gi\cii  after  above  examination,  and  during  the  week  subsequent  to  the 
attacks,  patient  has  become  much  better,  coughing  much  less,  respiration 
easier  and  there  is  less  ditiiculty  in  taking  the  stomach  tube.  Sensation 
over  thighs  and  legs  more  acute.  .\rea  about  rectum  and  over  buttocks 
supi)lied  by  the  sacral  nerves  remains  without  any  sensation  for  pressure 
or  pain.  Radiogram  shows  enteroliths  in  rectum.  Diagnosis.  The  case 
presents  the  characteristics  of  a  disseminated  myelitis,  located  mainly  in 
the  lumbar  and  cervical  regions  It  is  apjiarentlv  due  to  pressure  and 
irritation  of  the  s])inal  nerves  and  their  root  zones  (especially  sensory) 
by  bony  inflammatory  ]:)roducts,  and  to  the  same  pressure  upon  the 
medulla,  aft'ecting  the  vagus  noticeably  after  the  union  of  its  sensory 
and  motor  bundles.  It  is  possible  tliat  the  same  underh'ing  cause  has 
brought  about  both  the  myelitis  and  the  osteo-arthritis,  and  in  view  of 
the  fact  of  tlie  patient's  improving  so  noticeably  since  lieing  upon  mercur\', 
I  should  regard  syphilis  as  the  causative  agent.  The  affection  is  largely 
sensory  in  character  and  the  parallelism  between  the  symptoms  aft'ecting 
the  centers  in  the  medulla  (deglutition,  coughing,  respiration,  etc.)  and 
those  in  the  lumbar  region  (sacral  segments),  is  very  striking,  it  being 
observable  that  oidy  Miluntary  activity  is  possible,  such  as  starting  the 
act  of  deglutition  or  of  micturition,  but  all  those  reflexes  depending  upon 
sensory  stimulation  are  either  abolished  or  greatlv  crippled."  The  fol- 
lowing is  an  illustrative  case  of  esophageal  motor  paralysis: 

Xellie  S.,  aged  21  years,  referred  by  Dr.  J.  E.  Gross  for  graduallx' 
increasing  difficulty  in  swallowing.  Difticultv  in  s]5eech  had  lasted  three 
weeks.  There  was  no  nausea,  no  regurgitation  of  food,  bin  on  attempt- 
ing to  swallow,  choking  and  coughing  ]iroiiiptly  followed  and  the  food 
came  back  immediately.  The  patient  had  not  lieen  able  to  swallow  liquid 
for  the  last  four  days,  and  was  in  an  extremeh-  serious  state  of  water 
hunger.  ( Jn  examination,  the  nio\ement  of  the  palate  was  defective, 
but  there  was  a  slight  movement  of  irregiUar  character.  Pus  was 
streaming  down  from  the  sinuses  jiosteriorly.  The  pyriform  sinuses 
were  full  tf)  overflowing  with  secretion.  The  movements  of  the  tongue 
were  sluggish.  iMiunciation  was  very  imperfect  and  difficult  to  under- 
stand. The  patient  was  languid,  extremely  feeble  and  emaciated.  Ksopb- 
agoscopy  caused  no  inconvenience  after  draining  out  all  of  the  fluid 
in  tlie  pharynx.  The  eso])hageal  mucosa  was  exceedingK  pale,  and  no 
sign  of  cricopharyngeal  contraction  was  apjiarent.  The  intra-thoraeic 
portion  was  enlarged  by  the  negative  iiressure  of  inspiration  ratlier  more 
tluui  u>tial.      Ili.tl.il  I'ontraction  was  about  normal  for  a  feeble  person  re- 


oGO  DISEASES  OF  THE  ESOPHAGUS. 

laxed  by  water  hunger,  and  examined  without  anesthesia.     Dr.  W.   K. 
Walker,  after  a  careful  neurologic  examination,  reported  as  follows : 

"The  patient  presents  dysarthria  and  dysphagia,  with  paresis  of  the 
muscles  of  the  lips,  tongue,  palate  and  pharynx.  Closure  of  the  eyelids 
is  weakened.  Though  there  is  general  weakness,  it  is  not  more  than  can 
be  accounted  for  by  weeks  of  deprivation  of  nourishment  and  fluids, 
through  inability  to  swallow.  There  are  no  sensory  disturbances ;  hand- 
grasp  is  of  fair  strength ;  gait  is  normal.  Deep  reflexes  of  upper  ex- 
tremities are  normal.  Knee  jerks,  right  and  left,  are  absent.  Respiration 
is  entirely  costal  and  there  is  marked  breathlessness  and  tachycardia 
after  esophageal  tube  feeding.  There  is  no  marked  weakness  of  the  jaw 
muscles;  neither  is  there  involvement  of  the  bladder  or  rectal  muscles. 
The  mind  is  clear.  Diagnosis :  Myasthenia  gravis  or  asthenic  bulbar 
palsy.''  The  patient  was  given  water  and  liquid  food  with  a  stomach 
tube  and  gained  slightly  in  weight,  but  died  after  about  two  months  from 
paralysis  of  respiration.  Dr.  Edward  E.  Meyer,  the  neurologist,  under 
whose  care  she  was  at  this  time,  was  unable  to  obtain  an  autopsy. 

Endoscopic  appearances  of  paralysis  are  characteristic  if  the  paraly- 
sis is  complete.  There  is  noted  an  absence  of  the  spasmodic  contraction, 
which  usually  characterizes  an  esophagoscopy  without  anesthesia.  This 
is  most  noticeable  at  the  cricoid.  At  the  hiatus,  no  lessening  is  usually 
noticed  in  the  degree  of  contraction,  probably  because  these  contractions 
are  dependent  largely  on  the  diaphragmatic  musculature,  which  mav  not 
be  involved.  The  esophagus  is  apt  to  be  quite  flaccid  and  it  is  also 
unusually  insensitive  to  the  introduction  of  the  tube,  even  though  the 
paralysis  be  purely  motor.  If  the  patient  has  been  able  to  take  any  food, 
particles  adherent  to  the  esophageal  wall  may  be  noted.  Their  absence, 
however,  is  not  to  be  taken  negatively. 

Etiology.  The  causes  of  esophageal  paralysis  may  be  classed  under 
four  heads.  1.  The  toxic  type,  such  as  diphtheritic  paralysis.  2. 
Purely  functional  paralysis,  as  in  hysteria.  3.  Peripheral  paralysis  as 
from  neuritis.  1.  Central  paralysis  is  usually  from  a  bulbar  lesion,  as 
in  glosso-labio-])haryngeal  paralysis.  The  latter  condition  may  be  luetic 
as  may  also  the  neuritis. 

Diagnosis.  The  most  common  diagnostic  error  is  to  mistake  eso- 
phageal paralysis  for  hysteria.  When  a  patient  is  starving  for  food  and 
water  and  complains  of  inability  to  swallow  and  the  esophagus  is  seen 
on  esophagoscopy  without  anesthesia  to  be  free  from  spasm  at  the 
cricopharyngeus.  and  is  patulent  to  a  large  esophagoscope,  the  diagnosis 
of  hysteria  must  not  be  made  until  paralysis  is  excluded.  Flaccidity 
may  readily  be  mistakenlv  attributed  to  weakness  from  inanition.     But  if 


DISEASES  OF  THE  ESOPHAGUS.  561 

the  possibiliU'  of  paralysis  is  ke[it  in  mind  tlic  total  absence  of  the  normal 
spasmodic  constriction  at  the  cricopharyngeus  when  the  esophagoscopc 
is  passed  without  anesthesia  will  be  conclusive.  I'aralysis  of  the  esoph- 
agus is  practically  always  accompanied  by  other  paralyses  about  the 
upper  air  and  food  passages  that  are  distinctive  and  easily  recognized. 
Difticulty  of  swallowing  with  a  history  of  recent  diphtheria  should  al- 
ways bring  esophageal  paralysis  to  mind,  and  immediate  esophagoscopy 
should  be  done.  In  jjaralysis  of  esophageal  sensation,  the  reflexes  of 
coughing,  vomiturition  and  vomiting  are  absent  or  deficient  at  bronchos- 
copy and  esophagoscopy,  and  the  muscular  contraction  of  the  crico- 
pharyngeus is  feeble  or  absent. 

Treatment.  There  is  no  form  of  endoscopic  treatment  that  is  of 
any  use.  Esophagoscopy  is  of  value  in  determining  whether  or  not  there 
is  any  lesion  in  the  esophageal  lumen  that  would  contraindicate  the  pass- 
ing of  the  feeding  tube.  If  there  is  any  lesion,  such  as  sloughing  or  ero- 
sion, gastrostomy  should  be  done.  In  the  absence  of  such  lesions,  which 
are  rare,  the  patient  can  be  nourished  effectually  with  milk  put  in  through 
the  ordinary  stomach  tube.  The  treatment  will  then  dei>end  entirely 
upon  the  internist  and  the  neurologist. 

LUKS   OF   THE    ESOPH..\GUS. 

Luetic  disease  of  the  esophagus  is,  relatively,  a  rare  disease,  though 
it  is  not  as  rare  as  the  standard  literature  on  the  subject  would  seem 
to  indicate,  for  two  reasons.  1.  Prior  to  the  days  of  esO])hagoscopy, 
but  little  was  known  of  esophageal  disease,  except  what  happened  to  be 
found  at  post  mortem.  2.  The  esophagus  is  rarely  explored  at  autopsy- 
Prior  to  the  days  of  esophagoscopy,  a  few  diagnoses  of  luetic  disease  of 
the  esophagus  were  made  solely  upon  the  fact  that  difficulty  in  swallow- 
ing disap])earcd  upon  the  administration  of  specific  treatment.  Neces- 
sarily, this  leaves  a  large  possibility  of  error.  Such  cases  might  be 
si)asni  or  compression.  The  esophagoscopc,  however,  has  demonstrated 
that  luetic  disease  of  the  esophagus  may  show  itself  either  as  a  mucous 
plaf|ue,  a  gumma,  an  ulcer,  or  a  cicatrix.  In  llu-  absence  of  associated 
lesions,  it  is  not  jiossible  to  make  the  diagnosis  on  the  esojjhagoscopic 
appearances  alone.  They  must  be  taken  along  with  the  history,  the  con- 
comitant lesions,  the  thera])eutic  test,  the  W'assermann  test,  the  luetin  test, 
the  examination  of  tissue  and  a  search  for  spirochetes.  In  the  cicatricial 
form,  the  absence  of  any  other  cause  for  a  cicatrix  coming  on  late  in 
adult  life,  should  arouse  a  strong  suspicion  of  lues.  \\'here  there  is 
a  history  of  ditticulty  in  swallowing  in  childhood,  there  is  always  a  pos- 
sibility that  the  swallowing  of  some  caustic,  or  the  traumatism  of  a  for- 
eign body  may  have  been  overlooked,  and  as  suggested  by   .Mr.  Tilley, 


562  DISKASI-S  <)K  TlIK  KSOI'IIAGUS. 

the  possibility  of  the  late  manifestation  of  congenital  stenoses  must  he 
borne  in  mind. 

Esophageal  luetic  stenosis,  like  the  same  condition  following  any 
other  form  of  ulceration,  is  very  apt  to  give  the  history  of  difficulty  of 
swallowing,  which  improves  as  the  ulcer  heals  and  then  comes  on  with 
renewed  severity  as  the  scar  contracts. 

Bsopliayoscopic  appearances.  In  considering  the  esophagoscopic  ap- 
pearances of  lues,  it  is  necessary  to  remember  that  the  appearances  in  ul- 
cerative stage.s  are  due  largely  to  the  mixed  infection';  and  the  resultant 
inflammatory  condition.  The  same  is  true  of  tuberculosis  and  of  cancer 
when  these  have  reached  the  ulcerative  stage.  The  differential  diagnosis 
of  the  various  ulcerati\-e  lesions  in  the  esophagus  is  considered  under  "L"i- 
ceration  of  the  Esophagus."  The  mucous  platjue  of  the  esophagus  looks 
quite  similar  to  that  seen  in  the  fauces.  It  may  be  slightly  elevated  in  one 
part,  and  simply  a  bluish  white  cloudiness  in  another  part.  The  lesion 
is  typically  inflammatory  in  character.  The  cicatrix  of  luetic  esophagitis 
does  not  dift'er  from  other  cicatrices.  The  esophagoscopic  picture  of  a 
scar  which  involves  only  a  small  portion  of  the  ring  of  the  esophagus,  is 
very  apt  to  present  a  linear  appearance  on  esophagoscopy  for  purely 
mechanical  reasons,  inherent  in  the  inspection  of  the  interior  of  a  col- 
lapsed tube,  which  is  explored  by  an  endoscopic  tube  (see  Fig.  It.  Plate 
III).  The  gumma  of  the  esophagus  does  not  differ  materially  in  appear- 
ance from  gumma  seen  anywhere  else  in  the  mucosa,  except  in  so  far  as 
it  is  an  endoscopic  instead  of  a  right-angled  view.  The  foregoing  is  a 
brief  description  of  the  various  lesions  as  seen  by  the  author.  Xo  one 
has  seen  a  sufficient  number  of  cases  to  be  able  to  classify  the  endoscopic 
pictures,  and  even  though  it  were  possible  to  do  so,  the  diagnosis  wotild 
necessarily,  here  as  elsewhere,  rest  upon  the  laboratory  findings,  the 
therapeutic  test  and  the  concomitant  lesions. 

Treatment.  The  treatment  of  luetic  esophagitis,  as  with  the  same 
infection  elsewhere,  is  altogether  systemic  and  not  local.  One  point, 
however,  is  of  great  importance,  and  that  is  to  prevent  the  cicatrices 
from  contracting  after  the  healing  of  ulceration,  should  the  esophagos- 
copist  be  so  fortunate  as  to  encounter  the  case  in  the  ulcerated  stage. 
Unfortunately,  howe\er,  he  is  much  more  apt  to  see  it  in  the  cicatricial 
stage  when  the  mechanical  treatment  required  for  cicatricial  stenosis  must 
be  instituted.  In  the  stage  immediately  following  the  healing  of  the  ulcer, 
the  scar  can  be  prevented  from  contracting  if  a  silk  woven  bougie  is 
passed  every  day,  and  left  in  situ  for  a  half  hour  or  longer.  The  bougin- 
age  should  be  done  by  the  esophagoscopist  himself  under  the  direct  guid- 
ance of  the  eye.  Once  established,  cicatrices  of  luetic  origin  are  ex- 
ceedingly stubborn  to  treat,  and  may  re(|uire  the  string-cutting  esophago- 


DISKASKS  Ol"  Tin:  I'.SOPHACL'S.  563 

tome  or  otlior  loriii  of  internal  esophagotomy.  followi-d  liy  daily  dilata- 
tion. Comi)lcte  cure,  as  in  the  case  illustrated  in  Fii;.  ll'>,  will  reward 
l)atient.  carefid   work. 

TUl!i:KCfl.()SlS  Ol-'   THE   i;soriiAGus. 

Tnlierculosis  ol  tile  esophai^us  while  relati\el\-  mueli  more  rare  than 
the  same  process  in  other  viscera,  ne\ertheless  is  ])rohalily  not  so  rare 
as  the  literature  on  the  suhject  would  seem  to  indicate,  hecause  in  all 
proljaliilit\  it  usually  occurs  in  ]'atients  with  advanced  |iulinonary  lesions 
in  which  the  dithculty  in  swallowing  is  Init  a  minor  addition  to  the 
rapidly  fatal  stage  of  the  disease.  The  ditiicultv  in  swallowing  is  often 
considered  to  he  a  part  of  the  laryngeal  trouhle.  in  some  instances  the 
larynx  is  not  even  examined  hy  the  internist,  and  in  other  instances  it  is 
probable  that  laryngeal  tuberculosis  coexists  with  the  esophageal,  and  is 
considered  to  account  fully  for  all  dysi)hagic  symptoms.  Furthermore, 
the  disease  has  received  such  scant  consideration  in  medical  literature 
that  it  is  not  likely  to  Ijc  thought  of,  even  in  a  manifestly  tuberculous 
patient.  The  disease  may  occur  as  a  primary  infection,  or,  more  fre- 
(juently,  as  an  extension  from  a  tuberculous  jjrocess  in  the  larynx,  medias- 
tinal lymphatics,  pleura,  the  larger  bronchi,  or  e\eii  the  lung  itself.  When 
seen  as  an  extension  frcjiii  the  larynx,  especialh-  as  "party-wall"'  lesions, 
the  eso])hageal  lesions  i)resem  nnicli  the  same  picture  as  the  lar\ngeal 
disease.  A\'hen,  however,  they  are  primary  in  the  eso])hagus,  the  endos- 
copic ajjpearances  are  rather  those  of  superlicial  ulceration  or  a  simple 
erosion  and  there  mav  be  \ell(i\\isli  or  whitish  granules  in  the  neighbor- 
hood of  the  erosions  or  ulceration,  or  the  granules  may  exist  alone. 
Open  ulceration  means,  necessarily,  secondary  mixed  infections,  which 
modily  the  picture.  Cicatrices  have  been  observed  onlv  twice  li\-  the 
author,  once  in  cunnection  with  ulceration,  and  once  in  connection  with 
an  invasion  of  the  esophagus  by  iieri-bronchial  tuberculous  glandular 
processes.  \\  lieu  the  disease  in\;ides  the  esophagus  from  the  surround- 
ing tissues  in  the  mediastinum,  there  is  more  or  less  ct)mpression  of  the 
esophagus,  and  rigidity  and  fixation  with  very  much  impairment  of  the 
normal  esophageal  movements  and  the  transmitteil  respiratory  and  pul- 
satory movements.  The  tuberculous  |)rocess  ma\-  h,i\e  been  found  to 
be  completely  healed  ;ind  the  result  of  the  cicatricial  contraction  ma\  be 
in  rare  cases,  a  traction  dix  erticuhun.  The  author  has  seen  one  such 
case  esophagoscopically.  The  mncosa  did  not  differ  much  from  the  nor- 
mal, except  that  it  was  whiter  in  color  with  \essels  visible,  and  did  not 
have  the  velvet)'  appearance  of  i.onnal  mucosa.  The  fixation  was  very 
marked  and  could  easily  be  demonstraled  li\'   ir.iclion  upon   the  opposite 


564  DISEASES  OF  THE  ESOPHAGUS. 

wall  with  the  distal  end  of  the  esophagoscope.  demonstrating  clearly  that 
the  involved  wall  was  partly  adherent  to  the  peri-esophageal  structures. 
In  one  of  the  author's  cases  a  fistula  existed  from  the  esophagus  through 
into  the  left  bronchus.  The  esophageal  end  of  the  fistula  was  covered 
with  reddish  granulations,  wliich  bled  freely  when  touched,  while  the 
bronchial  end  of  the  fistula,  on  bronchoscopy,  was  seen  to  be  surrounded 
with  a  pale  mucosa,  with  small  whitish  granular  elevations  in  groups  at 
various  points.  The  granulations  were  pale  and  did  not  bleed.  They 
were  limited  to  the  margin  of  the  fistula,  and  did  not  seem  so  exuberant 
as  in  the  esophagus.  The  ulcerations  of  esophageal  tuberculosis  usually 
are  more  superficial  and  less  inflammatory  in  appearance  than  either  can- 
cer or  lues.  Some  points  of  difference  from  these  and  simple  ulcer  are 
given  under  the  head  of  inflammation  and  ulceration,  Imt  the  diagnosis 
of  tuberculous  lesions  here,  as  elsewhere,  will  rest  largely  on  the  labora- 
tory findings.  Esophagoscopy  renders  its  greatest  service  in  being  able 
to  obtain  with  precision,  ample  specimens  from  the  lesions.  Actinomy- 
cosis has  occurred  in  the  esophagus,  though  the  author  has  never  seen  a 
case.  The  possibility  should  be  borne  in  mind  in  the  examination  of  speci- 
mens of  supposed  tubercidosis.  In  considering  the  esophagoscopic  ap- 
pearances of  tuberculosis,  it  is  necessary  to  remember  that  after  ulcera- 
tion has  set  in  that  the  mixed  infections  are  apt  to  run  riot  and  that  the 
appearance  may  be  largely  due  to  the  secondary  processes  resulting  from 
this  inflammation.  One  characteristic  of  the  few  tuberculous  lesions  that 
the  auti'.or  has  seen  in  the  esophagus,  is  the  marked  absence  of  vas- 
cularity. The  mucosa  seems  pale  and  the  patches  whitish,  with  minute 
dots  of  raised  whitish  color.  In  one  of  the  author's  cases  there  was  so 
much  stenosis  of  the  esophagus  that  the  entire  mucosa  for  some  distance 
above  the  tuberculous  lesions  was  so  pasty  from  maceration  that  it  was 
difiicult  to  outline  the  lesion,  and  it  was  not  until  after  three  or  four 
weeks  of  absolute  rest  of  the  esophagus,  following  a  gastrostomy,  that 
the  esophagoscopic  appearances  of  the  tuberculous  lesion  itself  could 
be  determined.  This  patient,  a  man  of  .'U  years,  referred  by  the  Pres- 
byterian Hospital  Dispensary,  imjjroved  very  much  after  gastrostomy 
and  a  feeding  of  large  quantities  of  milk  and  eggs  through  the  gastros- 
tomy tube,  together  with  absolute  rest  in  bed.  There  was  a  fibroid 
phthisis  in  the  lung,  but  no  involvement  of  the  larynx.  The  view,  Fig. 
15,  Plate  III,  is  made  from  a  drawing  by  the  author  and  represents  con- 
ditions after  the  swallowing  had  very  much  improved  and  there  was 
practical  freedom  from  dysphagia.  The  mucosa  surrounding  the  tuber- 
culous lesions  is  seen  to  be  normal,  while  the  lesion  itself  is  of  a  dull 
grayish  color  and  there  is  a  total  absence  of  visible  vessels.  A  specimen 
of  tissue  examined  bv  Dr.  W'illetts  showed  the  lesion  to  be  tuberculous. 


13ISEASKS  OF  THE  IvSOPII  AOUS.  .5G5 

Treatment.  Local  treatment  is  useless.  A  general  anti-tulierculoiis 
regime  is  needed,  and  al>ove  all,  if  there  is  any  serious  difficulty  in  swal- 
lowing, gastrostomy  should  be  done  at  once  for  feeding  in  order  not  to 
let  the  [)atient's  nutrition  suffer,  for  above  all  things,  nutrition  must  be 
kept  at  the  highest  possible  point  of  efticiency.  Feeding  with  a  stomach 
tube  can  be  done,  but  it  is  exceedingly  dangerous  in  the  presence  of  ul- 
ceration, and  is  in  some  cases  painful  to  the  patient.  Above  all,  a  gas- 
trostomy puts  the  esophagus  at  rest,  which  is  beneficial  to  any  form  of 
esophageal  disease.  Orthoform  in  doses  of  half  a  gramme  swallowed 
drj-  on  the  tongue  may  be  used  if  there  is  pain,  though  none  of  the  au- 
thor's cases  of  tuberculosis  of  the  esophagus,  where  the  larynx  and  epi- 
glottis  were  uninvohed,  have  had  pain. 

V.'VKIX   .■\\D  .\NGIOMA  oF  THE   ESOPHAGUS. 

J'ari.v  and  angioma  of  the  esophagus  rarely  produce  symptoms,  and 
are  not  ordinarily  of  very  much  importance  unless  they  are  wounded  or 
they  spontaneously  bleed.  Occasionally  a  case  is  encountered  where  there 
is  considerable  bleeding,  the  patient  complaining  of  regurgitating  blood, 
which  is  bright  red  and  not  of  the  dark  or  "coffee  ground'  character  of 
blood  that  has  been  in  the  stomach.  V'aricositles  in  the  esophagus  may 
coexist  with  "cardiospasm."  W  hich  was  the  primary  lesion  has  not  yet 
been  determined.  In  one  of  the  author's  cases  hemorrhoids  and  varicosi- 
ties on  both  legs  were  enormous.  \'aricosities  are  usually  in  the  lower 
third  (if  the  esophagus,  jiroliably  because  the  veinous  system  is  more  de- 
veloped there  than  higher  up.  These  veins  empty  chiefly  into  the  portal 
vein  and  a  number  of  cases  have  been  rei)orted  where  the  condition 
seemed  to  depend  upon  obstruction  of  the  portal  circulation,  as  in  hepatic 
cancer  or  cirrhosis.  Careless  esoi)hagoscopy  producing  undue  pressure 
against  one  lateral  w-all  will  cause  an  exudation  of  blood  into  the  sub- 
mucosal tissue  forming  a  hematoma  (Fig.  l."):i)  which  has  been  mis- 
taken by  a  number  of  esophagoscopists  for  a  varicosity  or  an  angioma. 
The  author  has  had  no  experience  in  treating  varix  or  angioma  because  the 
few  cases  seen  by  him  did  not  require  treatment.  Guisez  reports  the 
cure  of  a  case  of  angioma  at  the  cardia  by  means  of  r.ulium,  and  this 
method  seems  to  he  particularly  appropriate. 

ANCIONEfKOTlC    EDEMA. 

The  author  has  not  been  so  fortunate  as  to  see  a  case  of  angioneurot- 
ic edema,  but  a  very  interesting  observation  of  this  disease  is  reported 
by  Arrowsmith  (Bib.  S),  who  is  an  expert  endoscopist  of  large  experi- 
ence. A  woman,  aged  50  years,  complained  of  difficult  and  painful 
swallowing  of  a  few  weeks'  duration,  with  history  of  previous  similar 


.'iliG  DISEASES  OV  THIC  ESOPHAGUS. 

trouble  of  indefinite  duration.  Esophagoscopy  by  Dr.  Arrowsmith  showed 
"a  mass  just  below  the  cricoid  cartilage,  filling  two-thirds  of  the  lumen 
of  the  esophagus,  with  its  attachment  centered  on  the  left  side,  .\llo\v- 
ing  for  the  distension  of  the  esophagus  by  the  tube,  this  mass  undoubt- 
edly almost  occluded  it,  when  mechanical  stretching  was  absent."  The 
mass  was  also  seen  by  Drs.  F.  C.  Pafifard  and  I,.  Grant  llaldwin.  Lues 
being  excluded  the  logical  diagnosis  of  neoplasm,  probably  malignant 
was  made  tentatively,  and  the  case  referred  to  the  author  who  found  the 
esophagus  normal  and  hence  concluded  the  stenosis  must  have  been 
spasmodic.  On  further  investigation  of  the  case,  including  the  testimony 
of  the  patient's  previous  medical  attendants  clear  history  of  angioneurot- 
ic manifestations  were  discovered  by  Dr.  Arrowsmith  to  have  preceded 
the  esophageal  symptoms  and  later  to  have  accompanied  the  attacks  of 
tlysphagia  and  odynphagia.    These  manifestations  were  as  follows: 

"Commencing  with  fre(|uent  and  painful  urination  and  vesical  tenes- 
mus, there  would  be  an  extreme  irritation  of  the  urethra  and  meatus, 
with  external  appearances  suggesting  urethral  caruncle;  alicays  followed 
by  symptoms  of  marked  gastrointestinal  disturbance  and  of  pronounced 
pylorospasm.  Edema  of  the  larynx  placed  her  in  a  very  critical  condi- 
tion for  forty-eight  hours.  Two  months  later  she  had  a  similar,  though 
milder,  attack." 

Subsequent  attacks  of  angioneurotic  manifestations  were  character- 
ized by  pruritic  cutaneous  wheals,  urethral,  vesical  and  gastric  symptoms 
accompanying  the  attacks  of  dysphagia  and  odynphagia.  No  esophagos- 
copies  were  obtainable  after  the  two  mentioned,  one  showing  the  angio- 
neurotic eruption  in  the  esophagus  and  the  subsetiuent  one  showing  the 
esophagus  to  be  normal. 

Treatment,  if  any,  for  the  condition  wnuld  be  general  not  esophagos- 
copic.  Passing  of  a  feeding  tube  with  esophagoscopic  aid  might  be  needed 
if  the  attack  were  very  prolonged. 

.VCTINOMYCOSIS   OF   THE    ESOPHAGUS. 

.-Ictinoinycosis  the  author  has  never  seen.  Its  possibility  slmuld  be 
borne  in  mind.  Ijut  the  diagnosis  doubtless  will  rest  ui)On  the  histologic 
examination  of  a  specimen  removed  esophagoscopically.  Reports  of 
cases  so  far  have  been  autoptical. 

DEVIATION    OE    THE    ICSOPHAGUS. 

Deviation  nf  the  esophagus  is  seen  not  infre(|uentl_\  in  cases  of 
mediastinal  tumors.  The  author  has  encountered  one  very  interesting 
case  of  esophageal  deviation  associated  with  a  spine  deformed  by  a 
I)reviously  healed  \ertebral  tuberculosis  (Eig.  4:i<;a).  The  patient,  a 
woman  aged  41;  years,  was  referred  to  the  author  by  Dr.   ].  W .  Fairing 


DISEASES  Ol"  TJIK  KSOPUAGUS. 


.-)(i7 


fiir  the  removal  of  a  cliickun  Ijonc  from  the  esophagus.  'I'lie  author  readily 
found  and  esophajjoseopicallv  removed  the  chicken  bone  withoiU  anv  prob- 
lem of  interest  :  but  the  marked  deviation  was  so  rare  that  the  i)atient  was 
sent  for  a  radioo;ra[)h  from  which  to  make  an  illustration  (  I'ig.  -i:)"-ia). 
Fluoroscopy  with  bismuth,  by  Dr.  Iloyce.  showed  the  deviation;  but  the 
bismuth  bolus  went   down   so   rapidly  that  a  stomach  tube  was  used  by 


Fi(..  4.i-'a. — K:nliiij;r''pli  nl  ;'  wuniiiii,  ;i>;cc.l  4(1  Mar--,  sliuwiiig  a  deviation  of  tlit 
esophagus,  that  produced  110  symptoms.  A  stomach  lulu-  was  inserted  for  demon- 
stration.    (Radiograph  made  liy   Dr.  Rnsscll  li.  liog^s.    .\uthor's  case. ) 

Dr.  lioggs  for  ra(liogra])hy.  I)ou1)tless  the  esophagus  bad  been  dragged 
aside  by  the  deviating  spine;  the  dragging  being  facilitated  by  the  longi- 
tudinal esojjhageal  redimdancy  caused  by  the  shortening  of  the  straight 
distance  from  llu-  Inpopbaryux  to  the  hiatus.  The  patient  had  nexcr  had 
anv  esophageal  svmi)toms  and  the  deviation  would  not  have  been  discov- 
ered had  it  not  tieen  for  the  foreign  body  accident.  It  is  interesting  to 
note  that  bevond  ihe  following  of  the  de\iated  hnuen  there  \\a>  no  dilti- 
cult\  in  esophago>copv  notwithstanding  a  uiarked  anterior,  as  well  as 
lateral,  spinal  deviation. 


CHAPTER     XXXV. 

Gastroscopy.* 

The  interest  awakened  by  the  author's  work  (Bib.  369,  237,  239) 
has  borne  good  fruit.  In  different  parts  of  the  world,  earnest  workers 
have  been  perfecting  technic  and  instruments.  The  author's  early  con- 
tention that  safety  demands  that  introducing  shall  be  with  a  tube  devoid 
of  a  lens  system,  in  order  that  lesions  may  be  detected  and  avoided,  and 
that  the  axis  of  the  instrument  may  be  readily  kept  in  line  with  the  eso- 
phageal axis,  has  now  been  universally  accepted.  After  the  distal  end  of 
the  tube  has  reached  the  stomach,  a  plug  with  a  window  has  been  used 
in  the  proximal  end  of  the  tube  so  that  positive  pressure  from  an  oxygen 
tank  (Janeway)  or  a  hand  bulb  (Mosher)  may  be  used  to  push  away 
mucosal  folds,  and  when  a  lens  system  is  inserted  in  the  tube  in  the  form 
of  a  long  tube  with  a  window  in  the  side  of  the  distal  end,  an  excellent  view 
of  the  distended  stomach  is  obtained.  The  author  personally  can  testify 
to  the  beautiful  view  of  the  gastric  mucosa  obtained  in  the  Janeway  gas- 
troscope,  and  while  the  use  of  inflation  and  of  a  lens  system  for  gastros- 
copy is  at  least  thirty  years  old,  yet  the  optical  formula  and  the  par- 
ticular combination  of  illumination,  lenses,  inflation  apparatus  and  tubes 
in  the  Janeway  gastroscope  make  it  a  highly  efficient  instrument.  Excel- 
lent results  have  also  been  obtained  by  Moure  (Bib.  392),  Hill  (Bib.  200), 
Eisner  (Bib.  128)  and  others,  and  all  of  these  instruments  are  now 
doubtless  developed  to  a  point  where  the  personal  skill  of  the  operator 
counts  for  more  than  the  particular  instrument.  The  usefulness, 
safety  and  practicability  of  the  gastroscope  is  an  accomplished  fact. 
The  need  now  is  for  careful,  skillful  men  interested  in  the  stomach 
who  will  use  it.  The  laryngologist's  field  is  already  too  large  without 
adding  the  stomach.    The  value  of  gastroscopy  in  establishing  a  diagnosis 

•In  this  chapter  liberal  quotations  are  made  from  the  author's  Rapport  at 
the  International  Medical  Congress,  London.  1913.  and  from  his  paper  read  by 
invitation  before  the  New  York  Academy  of   Medicine,   Jan.    23,    1907. 


GASTROKCOPy.  5GSJ 

in  severe  and  oljscure  stomach  disease  has  hccn  ahundaiUly  pnived.  The 
tendency,  however,  to  resort  to  it  only  in  very  serious  conditions  often 
prevents  one  of  its  greatest  achievements,  which  would  be  in  the  early 
diagnosis  of  cancer  and  of  pre-cancerous  conditions.  When  endosco- 
pists who  have  developed  the  gastroscopic  technic,  arc  sufficiently  numer- 
ous and  sufficiently  skilful  so  that  the  physician  or  the  surgeon  may  feel 
justified  in  sending  them  cases  before  the  patient's  condition  becomes 
desperate,  gastroscopy  will  be  of  great  use  to  the  physician  and  surgeon, 
but  gastroscopy  probably  will  never  be  done  by  the  physician  or  the 
surgeon  himself.  He  will  take  the  endoscopist's  report  along  with  that 
of  the  radiographer  and  analyst  and  decide  as  to  the  best  handling  of 
the  case,  just  as  the  otologist  in  a  brain  case  takes  the  report  from  the 
internist,  the  laboratory,  and  the  ophthalmologist.  Unlike  tracheo- 
bronchoscopy and  esophagoscopy,  it  may  be  said  of  gastroscopy  that 
while  its  positive  reports  are  extremely  \aluable,  its  negative  reports  are 
less  so,  just  as  with  ophthalmoscopy  in  brain  disease,  the  Wassermann 
reaction,  and  many  other  of  our  most  valuable  aids  in  medicine  and 
surgery.  A  very  important  point  in  increasing  the  range  of  mobility  of 
the  distal  end  of  the  gastroscope  in  the  stomach  has  been  demonstrated 
by  Henry  Janeway.  It  consists  in  an  elevation  of  the  knees  of  the  re- 
cumbent patient  to  the  vertical  or  flexed  position,  as  this  relaxes  the 
abdominal  wall. 

Seven  years'  addiliunal  experience  have  shown  the  correctness  of 
the  statement  (liib.  'ii)\) )  that  there  is  no  huiiian  being  with  a  normal 
spine  and  a  normal  eso])liagus  into  whose  stomacii  a  straight  and  rigid 
gastroscope  cannot  be  readily  and  safely  introduced,  provided:  (1) 
The  i)atient  is  fully  anesthetized.  (2)  An  ojien  tube  of  light  construc- 
tion is  gently  passed  by  sight.  (;!)  The  patient's  head  is  held  in 
the  Boyce  position.     (4)     The  operator  is  a  skilful  esophagoscopisl. 

Statements  to  the  contrary  are  the  result  either  of  inexperience  or 
of  experience  with  gastroscopes  that  cannot  be  passed  by  sight.  Flexible 
guides  are  unnecessary,  rarely  of  aid,  and  are  dangerous.  The  inexperi- 
enced will  have  trouble  at  the  cricopharyngeus,  but  surely  no  esophagos- 
copisl will.  It  required  only  thirty-eight  seconds,  in  the  author's  clinic, 
for  Professor  Killian,  in  his  careful,  skillful  w-ay  to  pass  the  author's 
gastroscope  from  the  mouth  to  the  greater  curvature  of  the  stomach. 
The  writer  cannot  understand  why  so  many  authors  have  stated  that  they 
had  difficulty  in  passing  a  rigid  instrument  through  the  cardia.  All  diffi- 
culties are  o\ercome  by  carefully  following  the  directions  given  under 
"Introduction  of  the  Esophagoscope." 

It  is  true  that  we  do  not  always  get  a  complete  view  of  the  gastric 
mucosa,  but  as  Ilalstead  has  pointed  out  the  same  may  be  said  of   the 


."i^ll  C.ASTKOSCOPV. 

nasopharynx.  Indeed  the  author  knows  of  no  case  of  gastroscopy  where 
he  has  failed  to  get  a  view  of  the  stomach,  which  is  more  than  can  be 
said  of  the  nasopharynx  by  ordinary  methods  of  examination. 

Some  recent  experiments  by  Rosenow  in  the  production  of  gastric 
ulcer  by  the  injection  of  streptococci  opens  up  a  wide  field  for  gastro- 
scopic  study  on  the  dog. 

Mortality  of  gastroscopy.  That  there  is  practically  no  mortality  from 
gastrosco]iv  in  \ery  careful  hands  has  been  shown  by  the  replies  to  the 
author's  circular  letter  of  iiK|uiry.  Out  of  110  cases  done  by  eight  dif- 
ferent endoscopists  there  was  no  mortality  from  any  cause  within  two 
weeks  after  gastroscopy.  The  author  has  now  examined  the  interior  of 
2;5S  living  stomachs  with  the  peroral  gastroscope,  and  so  far  onlv  one 
patient  has  died  from  any  cause  whatever  within  one  month  after  the 
gastroscopy.  .  As  previously  reported,  this  patient  was  moribund  from 
a  bleeding  ulcer  of  the  stomach  when  admitted  to  the  hospital.  I'.ut. 
taking  the  figures  just  as  they  stand,  the  mortality  is  onl\-  a  fraction  of 
one  per  cent. 

'rcclinic  of  (/nstroscopy.  In  the  main  the  description  of  the  technic 
in  the  earlier  publication  (  liib.  Sii!))  is  correct  and  has  stood  the  test 
of  further  experience.  Introduction  with  mandrin  and  finger,  however, 
was  abandoned  by  the  author  before  the  book  was  off  the  press  and  the 
gastroscope  was  passed  by  sight  as  described  in  Chapter  X.  The  author 
still  uses  the  open  tube  gastroscope.  but  believes  that,  after  all  the  data 
thus  obtainable  have  been  noted,  the  use  of  a  lens  system  in  the  open 
tube  will  in  a  proportion  of  cases  yield  additional  information,  and  is  a 
\-aluable  acquisition.  The  advantages  of  the  open  tube  are  the  undis- 
torted  image,  the  facility  of  probing,  removal  of  a  specimen  of  tissue  or 
fluid,  siionging  awav  a  coating  of  secretions,  etc.  When  one  dilates  the 
stomacli  lie  pushes  its  walls  far  away  from  the  reach  of  the  tube  :  walls 
which  otherwise  would  collapse  over  the  tube  mouth,  to  be  examined 
and  palpated  by  the  probe  and  tube.  The  portion  of  the  stomach  near- 
est the  centre  line  of  the  body  is  the  most  easilv  examined.  The  col- 
lapsed stomach  is  relatively  small,  and  much  of  it  is  near  the  middle 
line  (Fig.  -l.'S:)).  ^^'hen  one  distends  the  stomach  he  pushes  most  of 
the  otherwise  ex])lorable  area  away  from  the  central  line  and  thus  later- 
ally out  of  range.  The  diaphragm  is  rendered  much  less  movable  when 
the  stomach  is  distended,  and.  furthermore,  thus  is  rendered  impossible 
the  practice  of  a  most  \akiable  part  of  the  technic.  iiamel}'.  the  luanipu- 
lation  of  the  abdomen  externally  by  an  assistant,  which  brings  into  view 
the  fundal  and  pyloric  ends.  A  lens  system  and  an  inflated  stomach 
prevent  .sponging  away  of  secretions  with  which  manv  lesions  are 
covered.     The  position   ;uid   shape  of  the  stomach   in  the  living  subject 


GAS'KROSCOPY.  iVl 

has  hecn  iimst  citrimisly  misunderslood.  Fig.  IHJ  is  traced  I'nmi  (nu-  of  tlic 
classical  tcxl-houks  on  anatomy.  Whatever  may  be  the  position  and 
shape  of  the  stomach  in  the  ca<huer  or  in  the  Hving  subject  after  the 
abdomen  is  opened,  it  was  certain1\-  not  in  an\-  such  |iosition  in  any  of 
the  ".^.'iS  cases  examined  gastroscopically  by  the  author  and  it  may  be 
said  that  the  stomach  is  of  such  shape  as  to  fit  whatever  space  is  avail- 
able at  the  particidar  moment.  Tlie  author's  method  of  oiitHnini;  the 
st(.>macli  is  to  find  a  gi\en  boundary  with  the  extreniit\-  of  the  tube.     The 


fi^ 


Fif'.  4.3.?. — Positicin  of  tlie  stomach  in  the  case  of  Isabel  A.  Crosses  show 
where  the  wall  of  the  stomach  was  iptentinnally  pusht'd  by  the  gastroscopc.  The 
schema  in  the  upper  right  hand  corner  shows  the  other  planr  of  the  stomach. 


rlistal  end  of  the  tube  is  felt  by  the  abdominal  |)alpalor,  who  makes  a 
mark  on  the  patient's  skin  with  a  skin  ])encil.  .\nother  ])f)sition  on  the 
boundarv  is  then  found  and  marked,  and  thus  a  series  of  marks  dot  the 
skin  of  the  abdomen  correspondin<,f  to  the  stomach  outlines.  .\n  obvious 
source  of  error  is  the  drajj  of  the  tube,  which  may  displace  the  stomach. 
This  can  be  .'uoided  by  a  careful  watch  lln-ou^b  the  lulu-  ,ind  care  to 
make  a  \ertical  insertion  for  each  mark.  This  gi\es  the  jiosition  of  the 
stomach  when  empty.  The  radios,n-;iph,  which  is  more  tjenerally  usefid. 
gives  the  jiosition  when  conlainiiig  fluid  or  food.  The  stomach  wall 
can  be  pushed  into  .-dmost  any  position,  as  shown  in  l'"it;.   \'.V-\,  which  illus- 


572 


GASTROSCOPY. 


trates  the  position  of  the  stomach  in  the  case  of  Isabel  A.  (Bib.  239). 
The  stomach  gave  the  impression  of  a  loose  bag  dangling  on  the  end  of 
the  gastroscope,  freely  movable  in  all  directions,  by  either  the  movement 
of  the  gastroscope  or  the  manipulations  of  Dr.  Harold  A.  Miller,  who 
was  palpating  the  abdomen  externally.  The  diagram  at  the  upper  right 
hand  corner  of  the  illustration  shows  schematically  the  other  plane  as  it 
appeared  to  be  when  gastroscopically  examined.  Passing  down  the  esoph- 
agus, as  soon  as  one  passes  the  cardia,  folds  and  wrinkles  are  en- 
countered, a  slight  deflection  bringing  either  the  anterior  or  the  posterior 
wall  into  view.     The  degree  of  motion  shown  in  Fig.  43;5  is  obtainable 


omy. 


Fig.  434. — Position  ot  the  stomach  as  shown  in  a  classical  text-book  on  anat- 


only  imdcr  the  relaxation  of  deep  anesthesia.  When  gastroscopy  is  at- 
tempted, under  morphine  narcosis,  as  Mikulicz  attempted  it,  the  muscula- 
ture of  the  diaphragm  pulls  upon  the  central  tendon,  so  that  the  gastro- 
scope is  guyed  rigidly  like  a  tent  pole,  and  if  the  stomach  can  be  entered 
at  all,  only  such  portion  can  be  inspected  as  lies  in  a  line  with  the  axis 
of  the  entry  of  the  tube.  When  relaxed  under  deep  anesthesia  the  hiatus 
esopliageus  does  not  relax  or  enlarge  so  as  to  permit  of  motion ;  but  the 
entire  dome  of  the  diaphragm  can  be  moved  sidewise  because  it  is  of 
dome-like  form.  If  it  were  a  tightly  stretched  membrane,  as  shown  by 
the  dotted  line  in  Fig.  43.5,  there  would  be  no  yield  in  any  direction  ; 


GASTROSCOPY. 


573 


tiut  being  arched  (as  shown  in  Fig.  A'A') )  its  "slack,"  as  one  might  say, 
permits  of  a  range  of  motion  of  from  JO  to  15  cm.,  provided  the  central 
tendon  is  so  relaxed  by  deep  anesthesia  as  not  to  be  pulled  upon  from  all 
sides  by  the  diaphragmatic  musculature.  A  range  of  lateral  motion  of 
seventeen  centimeters  was  observed  by  Dr.  J.  Hartley  Anderson  in  the 
opened  abdomen  of  a  living  patient.  This  movement  was  imparted 
solelv  bv  the  gastroscopist  manipulating  the  gastroscope  by  its  proximal 
end.  Dr.  Anderson  with  gloved  hands  grasping  the  gastroscope  could 
I)lace  it  anywhere  in  the  unopened  stomach,  and  any  part  of  the  wall 
could  be  moved  to  the  tube  mouth.    One  of  the  most  promising  fields  for 


Pic.  435. — Illustrating  tlic  anatomical  reasons  tor  the  wiile  range  of  molality 
of  the  gastroscope  in  the  stomach.  If  the  diaphragm  were  a  plane  or  tightly 
stretched  membrane  as  represented  l>y  the  dotted  line  a  gastroscope  in  the  hiatus 
could  not  be  moved  laterally.  The  dome  shape  permits  of  a  wide  lateral  range 
of  movement  because  of  redundancy,  provided  the  diapliraymatic  muscidatnre  is 
rela.\ed  by  deep  anesthesia. 


open  tube  gastroscopy  is  the  aid  rendered  by  the  endoscopist  as  an  as- 
sistant of  the  abdominal  surgeon,  who  will  assist  the  surgeon  not  only 
in  diagnosis,  but  in  the  operating  room  during  the  operation,  by  working 
ibrougli  llic  niiiulh  in  (.-oniinu'tidn  with  the  siu'geon  whose  hand  is  in  the 
opened  abdomen.  The  endoscopist,  of  course,  has  his  own  instrument 
nurse  and  sterile  organization  at  the  head  of  the  ]>atient,  entirely  sejiarate 
and  apart  from  that  of  the  abdominal  surgeon,  to  whom  the  endoscopist 


o7i  C.ASTROSCOI'V. 

can  give  a  prompt  report  on  the  interior  appearance  of  any  suspicious 
portion  of  the  stomach  wall  palpated  and  presented  at  the  tube  mouth 
by  the  surgeon.  The  suspected  tissue  is  placed  in  front  of  the  tube 
mouth  ]iv  the  surgeon  whose  hands  are  in  the  opened  abdomen  palpating 
the,  as  vet.  imopened  stomach.  Extensive  citation  of  cases  would  unduly 
expand  this  book.     A  few  will  serve  for  illustration. 

Case  I, XIX.  Daniel  B.,  aged  sixty-two  years,  was  admitted  to  the 
Western  Pennsylvania  Hospital  to  the  service  of  Dr.  John  W  .  ISoyce. 
complaining  of  feeling  weak,  and  of  loss  of  appetite,  emaciation,  and 
headache,  all  these  symptoms  appearing  gradually  about  one  year  pre- 
viously. There  was  no  nausea  or  vomiting.  The  temperature  was 
normal,  the  pulse  00,  and  the  respirations  v!4.  After  the  mouth  of  the 
gastroscope  passed  the  cardia.  in  the  first  -l  cm.  of  the  passage,  the  an- 
terior and  posterior  walls  of  the  stomach  opened  up  in  normal  folds 
ahead  of  the  tube  mouth.  Below  this,  however,  the  tube  mouth  entered 
a  cavity  with  smooth  unwrinkled  walls.  At  the  bottom  of  this  cavity 
was  a  crescentic  slit-like  depression  looking  somewhat  like  the  primipar- 
ous  OS  uteri  (C,  Plate  \').  When  the  mucosa  was  sponged  clean  of 
bubbly  secretion,  the  slit-like  depression  was  found  to  have  a  considerable 
depth,  which,  however,  was  not  probed,  although  to  have  done  so  would 
have  been  technically  easy  and  probaiilv  harmless.  The  surrounding 
mucosa  was  of  pale  pink  color,  without  rugae,  and  when  the  tube  mouth 
was  withdrawn  the  depression  was  still  visible  in  the  same  position  in  a 
cavity,  the  wall  of  the  stomach  at  this  point  being  evidently  held  open 
by  adhesions  to  the  abdominal  parietes  or  viscera.  Fully  to  appreciate 
the  picture,  it  is  necessary  to  realize  that  the  empty  stomach  is  collapsed. 
When  examined  gastroscopically,  it  opens  up  ahead  of  the  tube  and  col- 
lapses after  its  w  ithdrawal,  in  a  manner  similar  to  that  of  the  vagina  upon 
the  introductiiin  and  withdrawal  of  the  \aginal  speculum  when  used  upon 
a  patient  in  the  dorsal  position.  But  here  was  a  case  in  which  the  an- 
terior wall  of  the  stomach  was  adherent,  so  that  it  was  held  up  ( dorsal 
decubitus  )  ;  thus  the  posterior  wall  dropped  away  by  gravity  and  left  a 
cavitN'.  The  cicatrices  and  adhesions  were  such  that  no  mucosal  folds 
could  be  ])roduced  in  the  neighborhood  of  the  slit.  When  Dr.  (Jgilvie 
tapped  upon  the  abtlomcn  the  vibrations  were  seen  to  be  beautifully  trans- 
mitted in  waves  over  the  upper  ( anterior )  wall  of  the  stomach.  The 
picture  was  beautifully  clear,  and  the  author  and  his  colleagues,  who  saw 
for  themselves,  felt  justified  in  pronouncing  the  lesion  the  cicatrix 
of  a  healed  i>erforating  gastric  ulcer.  Mad  it  been  an  operable  lesion, 
it  coulil  have  been  precisely  located  by  holding  the  tube  mouth  against  it 
while  the  abdominal  surgeon  cut  through  the  stomach  wall  from  the 
celiotomic  wound. 


GASTKOSCOl'V.  o75 

Case  XX.  Margjarct  7...  a  st-rsam  at  tlic  \\'estcrn  rennsylvania 
Hospital.  Six  months  hcforc,  gastrojejunostomv  had  been  performed 
by  Dr.  Cieorgc  L.  Hays.  Complete  symptomatic  cure  had  followed. 
Under  general  anesthesia,  the  author  passed  the  gastroscope,  and  readily 
found  the  anastamutic  opening;  in  the  form  of  a  slit,  which,  when  pulled 
open  b)-  the  instrument,  showed  a  slightly  puckered  border,  below  which 
could  be  seen  the  mucosa  of  the  jejunum  (.A.,  f'late  \  ). 

Dr.  W".  1.  Rodman,  with  my  assistance,  examined  gastroscopically 
a  gastrojejunostomy  wound  two  weeks  after  the  operation,  and  saw  the 
opening  and  the  non-absorbable  sutures  in  situ.  His  report  on  the 
examination  is  as  follows : 

■"The  patient  was  etherized,  brought  Ijefore  the  class,  and  the  gas- 
trosco]je  introduced.  Tt  was  surprising  to  me  how  well  the  interior  of 
the  stomach  could  lie  inspected.  The  gastroenterostomv  opening  was 
plainly  visible,  was  found  to  be  patent  and  working  perfectly,  and  the 
Pagenstecher  or  linen  thread  used  as  a  suture  material  was  ])lainly  seen. 
I  see  in  gastroscojiy  a  valuable  addition  to  our  diagnostic  resources  in 
gastric  diseases,  provided  the  instrument  can  be  employed  by  one  skilled 
and  deft  in  its  use.  Particularly  will  it  be  valuable  at  the  time  of  an 
exploratory  laparotomy,  inasmuch  as  the  gastroscope  can  be  so  guided 
that  even  the  j)ylr)ric  end  of  the  stomach  can  be  brought  clearly  in  view. 
The  case  above  referred  to  was  discharged  from  the  hos])ital  as  cured 
a  few  days  later,  lie  was  a  very  intelligent  F.nglisbman  and  was  com- 
forted by  the  assurances  gi\en  him  li\  Dr.  Jackson  after  an  inspection 
of  the  gastric  mucosa.  'i"he  patient  had  suffered  long,  had  become  ad- 
dicted to  morphia,  and  feared  that  he  had  carcinoma.  This  was  the 
first  time  that  gastroscopy  was  j)racticed  in  riiiladeli)hia.  1  ma\  add 
that  a  letter  received  months  after  his  return  to  I'jigland  stated  that  he 
was  enjoying  perfect  health.' 

'l"he  author  has  disco\ered  great  adxantagcs  in  jilacing  tlie  patient 
face  downward  with  a  pillow  under  the  chest,  and  in  some  instances 
under  the  peKis  also,  in  order  to  get  the  assistance  of  gravity  in  dro])- 
ping  forward  the  abdominal  wall.  It  is  not  generally  realized  the  extent 
to  which  the  sjjine  curves  forward  .-md  projects  into  the  alidomen  as 
well  as  MUo  the  tlioracic  cavities.  This  anterior  projection  into  the  ab- 
dominal cavity  interferes  seriously  with  gastroscopic  examination  oi  the 
pylorus,  because  in  the  dors.il  position  there  is  a  tendency  for  the  py- 
lorus to  drop  backward  and  reach  a  plane  ])oslerior  to  that  of  the  mid- 
dle portion  of  the  stomach  that  is  prevented  from  dropping  backward 
by  the  anteriorally  projecting  spine.  In  the  use  of  lens  systems,  the 
gastroscojiists  ha\e  been  misled  into  thinking  the\  were  looking  at  the 
pylorus,  when  really  they  were  looking  at  onl_\    a  more  or  less  fuiuiel- 


576  GASTROSCOPY 

shaped  cavity  formed  by  the  limited  area  of  the  stomach  wall  that  was 
inflated.  This  gives  in  miniature,  the  same  general  shape  as  the  pyloric 
antrum,  and  it  is  the  tendency  of  all  lens  systems  to  deceive  one  as  to 
the  actual  size  of  the  visual  field. 

Presbyopic  gastroscopists  should  have  a  special  pair  of  glasses 
with  a  60  cm.  focus,  as  the  glasses  for  ordinary  reading  distance  will  blur 
the  more  distant  gastroscopic  image. 

Gastroscopy  for  foreign  bodies.  The  esophagoscopist  is  often  con- 
sulted in  regard  to  foreign  bodies  that  have  reached  the  stomach.  The 
author's  opinion  is  that  the  great  danger  in  the  swallowing  of  foreign 
bodies  is  that  they  will  lodge  in  the  esophagus,  where  serious,  even  fatal, 
ulceration  may  occur.  Once  they  have  reached  the  stomach  they  are 
relatively  safe.  This  does  not  mean,  however,  that  it  is  ever  justifiable 
to  attempt  to  push  a  foreign  body  down  by  the  blind  methods,  or  by 
esophagoscopic  methods,  because  it  is  his  belief  that  any  foreign  body 
that  has  gone  down  through  the  mouth  can  be  brought  back  the  same 
way.  Xor  is  it  to  be  taken  that  once  a  foreign  body  has  reached  the 
stomach  that  the  patient  can  be  told  to  pay  no  more  attention  to  the 
matter.  On  the  contrary,  every  foreign  body  that  is  known  by  the  ray 
to  have  reached  the  stomach,  should  be  watched.  So  long  as  it  remains 
in  the  stomach,  it  is  relatively  safe.  When  it  reaches  the  intestines,  as  it 
usually  does  within  from  one  to  three  days,  it  should  be  watched  every 
alternate  day  radiographically,  in  order  to  make  sure  that  it  is  moving. 
Should  it  lodge  in  one  position  for  five  days,  a  laparotomy  should  be 
done  at  once  for  its  removal,  as  it  will  certainlv  perforate.  Quite  a  num- 
ber of  perforations  of  the  ileum  have  been  reported,  some  recent  cases 
by  SteifF,  Ross  and  Hodge.  The  author  had  one  case  in  which  consent 
to  esophagoscopy  was  refused  when  the  needle  was  in  the  esophagus. 
Later  when  lodged  for  five  days  in  the  intestines,  the  family  was  urged 
to  allow  a  general  surgeon  to  do  a  laparotomy.  Consent  to  this  was 
also  refused  and  the  child  died  of  a  septic  peritonitis  following  perfora- 
tion. 

Tn  all  cases,  great  care  should  lie  taken  to  avoid  cathartics. 
\'ery  bulky  foods,  such  as  potatoes,  bread,  oatmeal  and  the  like,  should 
be  given  freely  in  order  to  distend  the  bowel  and  embed  the  foreign 
body.  The  insane  and  the  intoxicated,  and  also  some  performers,  swal- 
low very  large  and  sharp  objects,  such  as  open  pocketknives,  glass,  etc. 
A  large  number  of  such  objects  have  been  removed  from  a  single  stom- 
ach. All  such  cases  deman<l  immediate  external  operation  by  a  general 
surgeon.  In  case  of  such  a  body  as  an  open  safety  pin,  the  author  would 
advise  laparotomy  by  the  general  surgeon  rather  than  take  a  chance  of 
its  not  perforating  in  passing  through  the  intestines,  because  of  the  com- 


GASTROSCOPV.  0(7 

hiiialion  (_)f  tliu  point  and  llie  sprin^i;'.  ll  is  ((uite  iiossihlc  that  it  mii;ht 
pass  harmlessly,  hut  on  the  other  hand  the  risk  of  perforation  is  great. 
Assisted  by  a  fluoroscopist  using  the  Grier  double-plane  fluoroscope,  the 
gastroscopic  removal  of  foreign  bodies  is  easy,  with  the  author's  gastro- 
sco])e. 

( )pen-tuhe  gastroscopes  (such  as  the  author's  esophagoscope  Fig.  19) 
are  the  only  forms  available  for  the  removal  of  foreign  bodies.  Forceps 
cannot  be  used  through  lens-system  gastroscopes. 

Castroscopv  tlvonoli  the  celiotoniic  wound.  For  this  purpose  a 
thick  short  tube  should   be  used.     .\  very  ingenious  speculum   for  the 


Fig.  43O. — A,  open  tube.  B,  light  carrier  to  be  used  during  introduction.  C, 
large  lamp  needed  uitli  lens  system.  11,  lens  system.  K,  open  tube  lor  use  witli 
large  lamp. 


purpose  has  been  devised  by  Robert  Rendu.     It  is  expansile  at  its  distal 
end  and  gives  a  large  visual  iield. 

I.ciis-svstciii  t/astroscopy.  .Alter  having  obtained  all  possible  data 
from  open-tube  gastroscoi)y,  a  lens  system  may  be  introduced.  The 
Tanewa)'  gaslroscf)i)e  is  shown  in  Fig.  bU!.  The  introduction  of  the 
open  tiilie  is  bv  the  author's  nicthnd  as  described  in  Chapter  X.  Th^-ii 
the  small  lamj)  carrier,  11.  is  withdrawn  and  the  large  lamj)  carrier,  C, 
is  introduced.  Next  the  lens  carrier,  I),  is  pushed  inside  of  the  hollow 
large  lamp  carrier.  The  lens  carrier  displaces  the  large  lamp  sidewise, 
permitting  l\\v  window  of  the  lens  system  to  jiroject  beyond  the  distal 
end  of  ihc  dpen  tube.  I  )xygen  from  a  tank,  or  air  fr(un  .a  cmiipression 
tank  (ir  liand  b.all.  is  then  used  to  distend  the  stomach  while  llie  degree 
of  distension   is   watched   through   the   tube.      It    seems   prnbable   that,   as 


378  GASTRoscopy. 

suggested  bv  Janeway,  the  air  or  oxygen  that  escapes  around  the  tube 
in  the  esophagus  would  prevent  an  injurious  degree  of  pressure.  This 
must  not  be  relied  upon,  however,  and  caution  against  over-distension 
is  advisable.  The  distended  area  in  the  stomach  assumes  a  funnel-like 
form  ending  at  the  apex  in  a  depression  with  radiating  folds  that  leads 
the  oliserver  to  think  he  is  looking  at  the  pylorus.  This  illusion  is  con- 
tributed to  by  the  foreshortenings  of  the  image  of  the  lens  system.  Prop- 
er comprehension  of  the  image  necessitates  familiarity  with  the  par- 
ticular instrument  used.  This  must  be  ac(|uired  by  practice  on  a  mani- 
kin which  can  be  readily  devised  from  an  open  box.  which  permits  com- 
parison of  the  image  with  the  corresponding  naked  eye  view. 

A  good  illustration  of  endoscopic  views  of  the  stomach  through  the 
Janeway  lens  system  is  shown  in  Plate  \'l. 


Part  II. 

Laryngeal  Surgery. 

I.\'I'R()DL:CTI()N. 

It  is  not  intended  here  to  teach  the  fundamentals  of  modern  aseptic 
surgery.  'I'lie  reader  is  supposed  to  have  had  a  number  of  years  of 
practical  training  in  a  good  clinic  under  a  master  of  surgery. 

Operatmy  room  organization.  Modern  surgery  is  not  the  work 
of  one  man  but  of  an  organization.  It  is  impossible  for  one  man  to  at- 
tend tf)  all  the  details  of  the  modern  operating  room,  and  he  is  dependent 
upiiii  tlie  conscience,  skill  and  ahilily  of  his  assistants,  nurses,  radio- 
graphers and  otliers.  The  organization  does  not  need  to  be  large,  but  it 
must  be  harmonious  and  each  must  work  for  the  common  good  rather 
than  to  satisfy  personal  ambitions.  Tlurc  must  be  no  failure  upon  the 
part  of  any  nurse,  instrument  or  apparatus  at  a  critical  moment,  in  short 
it  is  in  every  sense  of  the  word,  "team  work,''  and  ])ractice  together  is 
essential  for  the  best  results,  as  in  a  football  leani. 


CHAPTER     XXXVI. 

Acute  Stenosis  of  the  Larynx. 

For  the  present  purpose  any  condition  that  narrows  the  lumen  ot 
the  larynx  and  immediately  subjacent  trachea  in  a  relatively  short  time 
may  be  considered  an  acute  stenosis.  Such  narrowing  may  be  due  to 
a  foreign  body ;  to  accumulation  of  secretions  or  exudates ;  to  distention 
of  the  tissues  by  air,  inflammatory  products,  serum,  pus,  etc. ;  to  dis- 
placement of  relatively  normal  tissues  as  in  abductor  paralysis,  con- 
genital laryngeal  stridor ;  to  neoplasms ;  to  granulomata.  Two  or  more 
of  the  foregoing  may  be  combined.  In  fact,  the  stenosis  in  almost  all 
cases,  whatever  the  cause,  is  mechanically  increased  by  the  presence  of 
secretions,  temporarv  inflammatory  conditions,  etc.,  in  the  already  nar- 
rowed lumen. 

Edema  of  tlir  lary)ix  is  the  most  freciuenily  heard  of  acute  stenotic 
condition.  The  name,  however,  has  been  used  too  generally  in  the  ab- 
sence of  means  of  accurate  diagnosis  especially  in  children,  ]irior  to  the 
advent  of  direct  methods  of  examination  which  have  recently  rendered 
accurate  diagnosis  possible.  Edema  may  be  glottic,  supraglottic  or  suli- 
glottic.  Strictly  speaking,  the  name  glottis  refers  to  the  chink  or  lumen, 
and  cannot  be  affected  with  edema,  Xevertheless  the  bordering  tissues 
can  be  edematous,  and  "glottic"  in  this  case  is  used  to  mean  a  region. 
As  a  pathologic  fact,  however,  the  vocal  bands  are  rarely,  themselves, 
acutelv  edematous,  though  thev  are  fretpicntly  pushed  inward  by  the 
edema  of  the  basal  tissues,  and  thus  the  cortlal  edges  encroach  on  the 
glottic  lumen,  though  not  themselves  edematous.  .As  shown  by  Logan 
Turner  (  llib  ~ii2  1  the  loose  cellular  tissue  is  most  fre(|uentlv  concerned 
in  laryngeal  edematous  processes,  .\cute  inflammatory  stenosis  may  be 
associated  with  relatively  superficial  mucosal  and  submucosal  inflamma- 
tion or  with  perichondritis.  These  processes  may  be  primary  or  may 
com])licate  many  general  diseases,  especially  typhoid  fever, 

.-Iciite  larynqeiil  stenosis  cnm/'iicating  typhoid  fever  deserves  espe- 
cial consideration,  as  it  is  frequently  overlooked  and  the  patient  is  per- 
mitted to  die  without  a  suspicion  of  the  laryngeal  stenosis,  because  these 
patients,  in   many   instances,   make  no   fight    for  air  anil  often  are  only 


ACUTK  STENOSIS  OF  TlIK  LARYNX. 


581 


sliglitlv.  if  at  all,  affected  liy  Imarscncss  as  shown  hy  the  author  in  an 
extensive  stiuly  ni  the  larynx  in  typhoid  fever  (Kih.  2.52).  A  typical 
case  of  acute  stenosis  complicating  typhoid  fe\er  reported  by  J.  H.  Bryan 
I'Bib.  ofi ;  is  particularly  valuable  as  giving  an  accurate  description  of 
the  living  laryngnscojiic   ])icture  by   a  Ween,  experienced  observer.        A 


Fig.  4.V. — Photograph  of  spccinitn  of  larynx  acutely  stenosed  by  perichon- 
dritis complicating  typhoid  fever  in  a  man  aged  forty  years.  A,  gap  where  speci- 
men was  excised  post-mortem.  B,  necrotic  left  arytenoid  cartilage  hanging  by  a 
shred.  C,  necrotic  area  from  which  right  arytenoid  cartilage  necrosed  and  dis- 
appeared before  death.  I),  interior  view  of  trachootomic  wmnid.  Specimen  lent 
by  Maj.  Frederick  Russell,  l'.  S.  A.     I'atimt  of  Dr.  Jn>.cpli   H.  Bryan. 


photograjili  of  the  aiUoptic  s|iecinu'n  i>  repr(]duced  in  l'"ig  b'i7  by  cour- 
tesy of  Maj.  Frederick  1\.  Russell.  Surgeon.  U.  S.  A.,  who  kindly  lent 
the  author  the  specimen  from  the  .Museum  of  the  Siu-geon  (leneral's 
cilice.  .Acute  laryngeal  stenosis  in  typhoid  fever  may  be  due  to  cordal 
inmiobiliiy  from  either  paralysis  or  intlamniatory  arytenoid  fixation  in  the 
absence  of  edema. 


,583  ACUTK  STENOSIS  OF  TUK  LARYNX. 

Laryngeal  stenosis  in  the  new-born.  Another  class  of  cases  is  the 
children  born  with  laryngeal  stenosis  of  anomalous  morbid  or  traumatic 
laryngotracheal  stenosis.  Examples  of  these  are  not  common  compared 
to  the  number  of  births,  but  doubtless  are  usually  overlooked  when  they 
do  occur  because  they  are  simply  put  down  as  a  "blue  baby."  The  dis- 
tinguishing feature  is  that  whereas  a  "blue  baby"  from  failure  of  the 
foramen  ovale  to  close  is  pumping  the  air  in  and  out  regularly,  and  a 
"blue  baby"  from  apnea  does  not  make  the  respiratory  movements,  the 
laryngeally  stenosed  baby  is  making  the  respiratory  movements  but  little 
or  no  air  is  passing  in  or  out,  and  there  is  indrawing  at  the  suprasternal 
notch,  around  the  clavicles,  and,  in  some  cases,  even  in  the  epigastrium. 
The  following  case  communicated  to  the  author  by  Dr.  Freeland  is  so 
complete  and  accurately  observed  that  it  may  be  taken  as  typical. 

"Female  :  full-term :  7  pounds  ;  lived  twenty-four  hours.  Easy  for- 
ceps delivery.  Mother  had  right-sided  pyelitis  with  temperature  101  to 
103,  pulse  no  to  100,  for  three  days  before  delivery.  Cords  pulsating 
strongly  and  regularly  and  child  had  a  good  color  on  delivery.  Made  oc- 
casional voluntary  etiforts  at  inspiration,  but  gradually  passed  into  con- 
dition of  white  asphyxia.  Resuscitated  by  hot  bath  and  mouth  to  mouth 
artificial  respiration.  After  ten  to  fifteen  minutes  was  breathing  regular- 
ly and  had  a  good  color.  Never  cried.  Respirations  shallow.  From  this 
time  on  there  were  repeated  attacks  of  secondarv  asphyxia  from  which 
the  child  was  revived  with  oxygen  and  mouth  to  mouth  insufflation.  After 
four  to  six  hours  these  attacks  of  asphyxia  were  accompanied  bv  the  ex- 
cretion of  frothy  brownish  mucus  from  the  throat  and  lungs.  Respira- 
tions were  always  shallow  and  labored  and  the  accessory  muscles  con- 
tracted strongly  with  each  inspiration,  even  after  resuscitation  from  at- 
tacks of  asphyxia.  The  lungs  were  full  of  moist  rales,  the  respiratory 
nuirmur  was  \ery  short  and  much  less  pronounced  than  the  usual  in- 
fantile type.  Except  for  some  retraction  of  the  head  there  was  no  evi- 
dence of  cerebral  hemorrhage.  The  child  died  in  twenty-four  hours  in 
an  attack  of  asphyxia,  having  been  kept  barelv  alive  for  some  hours 
by  constant  watching,  oxygen,  removal  of  mucus  from  the  throat  and 
mouth  to  mouth  artificial  respiration.  It  never  cried,  a  point  that  did 
not  receive  much  attention  until  the  autopsy  was  performed.  The  clinical 
diagnosis  was  atelectasis.  Autopsy  was  performed  by  Dr.  Andrews,  who 
found:  Malformation  of  larynx,  sub-dural  hemorrhages,  bilateral.  He- 
matoma of  scalp,  right  side.  Subserous  hemorrhages  of  lungs  and  heart. 
Inflammatory  foci  in  right  lung.  vSubcutaneous  hemorrhages.  Anemia. 
Larynx;  cricoid  and  arytenoid  cartilages  are  much  thickened  and  firmer 
than  normal.  The  glottis  is  very  small,  just  atlmitting  the  head  of  a 
moderate-sized  probe.     The  vocal  cords  are  shortened,  thicker  and  firm- 


ACfTIC  STENOSIS  OF  THK  LARYNX.  583 

er  than  normal.     Kcmarks  :     The  patholojjy  found  wa.s  donlitless  all  sec- 
ondary to  the  laryns^cal  stenosis.     Death  was  by  asi)hyxia. 

The  author  has  seen  three  cases  of  acute  laryngeal  stenosis  from 
perichondriti-;  in  infants  a  few  weeks  old.  The  thymus  gland  was  large 
in  all  three  cases,  probably  due  to  the  vascular  engorgement  of  dysp- 
nea, and,  had  the  ciiildren  died,  the  death  would  have  been  attributed  to 
status  lymijhaticus.  In  each  of  the  cases  direct  examination  revealed 
laryngeal  stenoses  and  a  total  absence  of  thymic  or  any  other  tracheal 
comjiression,  and,  most  important  of  all,  tracheotomy  completely  relieved 
all  the  symptoms,  the  children  recovered  and  were  decannulated  after 
the  cure  of  the  laryngeal  stenosis.  As  to  the  cause  of  the  perichondritis 
the  author  is  unalile  to  say  positively.  The  cases  were  all  forceps  de- 
liveries, and  traumatism  either  during  accouchement  or  clearing  the 
mouth  and  pharynx  afterward  might  have  been  a  factor.  The  father 
of  one  of  the  patients  was  luetic,  but  neither  lues  nor  tuberculosis  has 
appeared  in  any  of  the  three  children  though  they  are  now  two,  three 
and  six  years  of  age  respectively.  The  stenotic  symptoms  began  in  all 
three  of  the  cases  between  the  second  and  the  fourth  week.  The  author 
at  i^resent,  has  another  similar  case  of  stenotic  laryngeal  ])erichondritis, 
starting  three  weeks  after  delivery  and  reaching  the  almost  fatal  point 
in  the  eighth  week,  'i'he  laryngeal  nature  of  the  trouble  was  recognized 
by  Dr.  W  illiani  Kirk  who  sent  the  case  to  the  author.  The  child  was  mori- 
bund from  stars atif)n  and  loss  of  sleep.  It  had  been  so  busy  fighting  for 
air  that  it  had  no  time  for  eating  and  sleei)ing.  The  left  side  of  the 
subglottic  region  was  bulged  in  until  there  was  only  a  slight  crevice  left 
through  which  to  breathe.  The  swelling  was  lirmer  than  an  edema  and 
contained  i)us.  The  author  did  a  tracheotomy  with  conii)lete  relief  of  the 
dyspnea  after  which  it  nursed  and  slept  normally.  A  quantity  of  muco- 
pus  escaped  from  the  trachea  as  soon  as  the  tracheal  incision  was  made. 
Like  all  the  other  patients,  it  gave  the  usual  tracheotomic  sigh  of  relief 
and  respiratory  pause  after  the  trachea  was  opened. 

'i'he  glottis  normally  is  relatively  narrow  in  the  newdiorn, 
Surcjical  treatment  of  acute  laryngeal  stenosis.  ^Multiple  puncture 
of  acute  inflammatory  edema  is  readily  accomplished  with  the  knife,  Fig. 
85,  used  through  the  direct  laryngoscope,  P"ig.  14.  As  a  rule,  however, 
this  is  by  no  means  certain  to  be  helpftU  for  any  length  of  time  and 
recrudescence  of  the  edema  may  be  fatal  in  the  absence  of  a  tracheotom- 
ist.  In  view  of  this,  and  especially  in  view  of  the  great  therapeutic  effect 
of  tracheotomy  in  all  intlannnatory  states  of  the  larynx,  tracheotonix' 
should,  in  most  cases,  be  done  in  ]ireference.  Intubation  is  treacherous 
mill  unreliable  in  all  excejit  diphtheritic  cases.  In  the  latter,  O'Dwyer's 
intubation  is  ideal,  if  the  p.alieiil  \k-  earefulK    watched. 


CHAPTER     XXXVII. 

Tracheotomy. 

INDICATIONS    FOR    TRACHEOTOMY.* 

As  a  therapeutic  measure  in  diseases  of  the  larynx,  tracheotomy 
should  occupy  a  more  prominent  place  than  has  ever  been  accorded  to  it. 
Whether  the  therapeutic  effect  is  due  to  rest  of  the  larynx  or  not,  the 
author  is  unable  to  say,  but  the  effect  in  many  diseases  is  abundantly 
proven  according  to  his  experience.  Inefficacious  antiluetic  treatment 
of  luetic  laryngitis  has  immediately  produced  results  after  tracheotomy. 
A  number  of  writers  have  discredited  tracheotomy  in  tuberculosis.  The 
author's  experience  has  been  quite  the  reverse.  In  a  number  of  cases 
with  advanced  laryngeal  tuberculosis,  but  with  relatively  slight  lung 
lesions,  marked  improvement  and  relative  cures  have  followed  tracheo- 
tomy, combined  in  some  instances  with  the  healing  of  ulcerations  and  the 
reduction  of  infiltrations  by  the  galvano-cautery.  These  jirocedures  en- 
abled the  patient  to  be  nourished  systematically  in  cases  in  which  the  pa- 
tient was  rapidly  declining  because  of  inanition,  owing  to  the  odynphagia. 
Tracheotomy  was  done  in  these  cases  only  partly  for  the  purpose  of 
rest  of  the  larynx,  but  mainly  to  permit  of  perfect  ventilation  of  the 
lung,  which  was  but  inefficiently  carried  on  through  the  narrowed  glottic 
chink.  Perichondritis  and  other  inflammations  of  any  etinlogv  are  often 
very  promptly  benefited  by  tracheotomy. 

Tracheotomy  for  foreign  bodies  is  no  longer  indicated  either  for  the 
removal  of  the  intruder  or  for  the  insertion  of  the  bronchoscope.  In  the 
absence  of  a  bronchoscopist  the  surgeon  is  perfectly  justified  in  relieving 
dyspnea  in  a  foreign  body  case  by  tracheotomy.  Tracheotomy  ma\-  be 
urgently  indicated  for  foreign  body  dyspnea,  but  not  for  foreign  body 
removal. 

/  ra'-heotomy  for  respiratory  arrest.  In  the  absence  of  anv  stenosis 
of  the  larynx,  tracheotomy  may  be  urgently  indicated  in  respiratory  ar- 

•This  chapter  is  a  revision  of  a  lecture  delivered  by  the  author,  by  invitation, 
before  the  Philadelphia  Laryngological  Society,  Sept.  23,  1913. 


TRAciii:oTOMv.  585 

rest  for  the  iiivitft'lation  of  oxygen  and  aniyl  nitrite.  (  Jrdinary  Sylvester 
artificial  resjjiration  is  much  more  et'ticient  if  a  tracheotomy  has  heen 
done  because  it  eliminates  the  pharyngo-laryngeal  "death  zone."  The 
pulmotor  and  similar  apparatus  are  fairly  efficient.  Bronchoscopic  oxygen 
insufflation  is  better  than  either,  if  available.  Paralysis  of  respiration 
in  bulbar  palsy,  cerebellar  abscess  and  the  like  may  produce  intense 
cyanosis,  for  which  tracheotomy  may  not  be  indicated.  lUit  unless  the 
diagnosis  is  certain  from  previous  study  of  tlie  case,  arrest  of  respiration 
with  cyanosis  is  always  an  indication  for  tracheotomy.  The  cause  can 
be  ascertained  later.  Many  times  more  i)eoiile  have  died  for  want  of  a 
tracheotomy  than  have  ever  died  from  the  operation. 

'i'here  comes  a  time  when  a  patient  luay  die  because  he  can  no  long- 
er stay  awake  to  breathe.  \\  hen  he  attempts  to  doze,  the  loss  of  the 
accessory  muscular  activity  de])ri\es  him  of  air  and  he  is  wakened  by 
threatened  asphyxia.  We  all  preach  early  tracheotomy,  but  practically 
always  do  it  late — dangerously  late.  Rarely  indeed  is  it  justifiable  to 
wait  for  cyanosis,  or  still  worse,  ashy  gray  '"cyanosis."  W  hen  res|)ira- 
torj'  arrest  comes  from  laryngeal  or  tracheal  obstruction  it  comes  abrupt- 
ly.    Five  factors  contribute  to  relatively  sudden  death  in  dyspneic  cases. 

1.  The  patient  from  waiU  of  sleep  reaches  the  point  where  he  can- 
not longer  stay  awake  to  breathe. 

2.  Secretions  accumulate  rapidly  toward  the  last  because  the  laryn- 
geal conditii'n   interferes  with  expectoration. 

'■).  The  patient  \\(irn  out  by  his  fight  for  air  gives  up  froiu  ex- 
haustion. 

The  foregoing  three  factors  ajiiil)  with  es|iecial  force  to  dyspnea  of 
gradual  onset  and  especially  in  children. 

4.  X'enous  engorgement  suildenly  increases  in  increasing  progres- 
sion as  dyspnea  increases.    Thus  a  vicious  circle  is  established. 

5.  \ny  excitement  or  struggle  increases  dyspnea,  hence  the  first 
steps  of  an  nperation  or  of  attem])ted  aj>j)lication  of  an  anesthetic  in- 
haler, preciiiitatcs  respiratory  arrest. 

It  is  particularly  dangerous  to  postpone  tracheotomy  over  night  im- 
less  a  good  experienced  tracheal  nurse  is  watching  the  patient.  Too 
often  nurses  who  are  ordinarily  good  and  well-trained,  but  inexperienced 
in  tracheotrmiy.  will  tliink  the  p.atient  is  "sinking"  when  reallv  be  is 
asphyxiating.  Death  Inr  want  of  a  tracheotomy  has  resulted  from  the 
failure  to  recognize  that  a  i)atient  with  a  monolateral  paralysis  is  in  con- 
stant danger  of  asphyxi.i  in  two  ways:  (  1)  The  iNiralysis  mav  become 
bilateral.  (2)  There  m;iy  !)e  bilateral  adductor  spasm  (or  si)asm  of  the 
mobile  cord  I.  The  first  of  these  is  more  often  recognized  than  the  lat- 
ter, for  it  does  not  seem  to  be  generalU'  known  that  se\ere  and  dangerous 


oSti  TRACHEOTtlMV. 

l)ilateral  spasm  even  in  a  palsied  cord,  may  be  caused  from  a  mediastinal 
pressure  effecting  both  the  afferent  and  efferent  vagal  fibers.  The  au- 
thor has  seen  such  cases.  If  a  patient  with  monolateral  recurrent  paraly- 
sis goes  where  he  cannot  be  watched,  he  does  so  at  his  peril.  Tracheo- 
tomy may  be  indicated  as  a  preliminary  procedure  to  laryngectomy  and 
other  procedures.  It  is  sometimes  needed  to  relieve  bechic  air  pressure 
in  order  to  obtain  healing  of  the  plastic  flap,  in  the  closing  of  tracheal 
fistulae.  Angioneurotic  edema  of  the  larynx  is  usually  an  urgent  indica- 
tion for  early  tracheotomy. 

Siihcutarcoiis  rupture  of  the  trachea  from  external  trauma  may  ne- 
cessitate tracheotomy  as  shown  in  the  following  case.  Tiie  author  was 
called  to  the  Presbyterian  Hospital  to  examine  a  case  of  extreme  dysp- 
nea and  cyanosis.  He  found  a  boy  of  fifteen  years  admitted  with  a  his- 
tory of  having  fallen  down  a  flight  of  steps,  striking  his  neck  across  the 
arm  of  a  chair  that  stood  at  the  foot.  Apparent  unconsciousness  for  a 
few  minutes  was  followed  by  pain  on  swallowing,  and  in  a  few  hours 
by  an  emphysematous  swelling  of  the  neck  which  gradualK'  extended 
over  the  entire  body  from  the  edges  of  the  scal]5  to  the  soles  of  the  feet. 
Severe  dyspnea  began  about  24  hours  after  the  accident.  Occasionally 
coughing  brought  up  a  considerable  quantity  of  bloody  mucus.  Indi- 
rect laryngeal  examination  was  negative.  Introduction  of  the  broncho- 
scope showed  the  trachea  full  of  bubbling  bloody  secretions  which,  when 
cleared  away,  showed  a  horizontal  wound  in  the  tracheal  mucosa  ex- 
tending from  the  front  of  the  trachea  around  the  left  side  about  the  level 
of  the  second  ring.  Below  this  the  trachea  was  compressed  to  a  scabbard 
shape.  Pushing  the  bronchoscope  on  downward  completely  relieved  the 
dyspnea.  The  bronchoscope  was  left  in  situ  while  a  long  incision  was 
made  in  the  front  of  the  neck.  When  the  trachea  was  reached  the  point 
of  rupture  was  found  to  be  between  the  first  and  second  rings.  The 
usual  vertical  tracheotomic  incision  was  made  c|uite  low  down  and  a 
long  tracheal  cannula  inserted  which  relieved  the  breathing  completely 
on  removal  of  the  bronchoscope.  The  emphysema  subsided  in  a  few 
days,  the  patient  was  decannulated  without  difficulty  and  a  prompt  re- 
covery ensued. 

Subcutaneous  rujiture  of  the  trachea  is  a  very  rare  accident  but 
there  are  a  number  of  cases  scattered  through  the  literature.  The  author 
believes,  however,  that  this  is  the  first  case  observed  bronchoscopically. 
It  serves  to  demonstrate  the  usefulness  of  the  bronchoscope  in  the  diag- 
nosis of  the  exact  mechanical  cause  of  dyspnea  and  also  demonstrates  the 
advantage  elsewhere  mentioned  of  using  the  bronchoscope  temporarily  to 
relieve  dyspnea  and  to  furnish  useful,  though  not  essential  aid  in  tracheo- 
tomy. 


TRACHEOTOMY. 


587 


Acromcaalic  stenosis  of  the  larynx  as  shown  in  Fig.  438  is  a  rare 
but  urgent  indication  for  tracheotomy.  Glottic  spasm  in  a  case  referred 
to  the  author  by  Dr.  M.  1,.  Stevenson  was  severe  at  times  and  would 
have  been  fatal  without  tracheotomy.  The  acromegalic  overgrowth  of 
the  larvn.x  was  so  great  that  the  slightest  spasm  would  shut  up  the  al- 
readv  narrowed  "lottic  chink. 


Fi<;.  438. — ^.Acromegalic  stenosis  of  the  larynx  in  a  man  forty  years  of  age.  The 
thyroid  cartilage  was  shown  by  a  radiograph  to  be  enormously  overgrown.  The 
massive  contonr  of  the  laryngeal  landmarks  corresponded  to  the  massive  facies. 
Frequent  glottic  spasm,  with  tlu-  narrowed  chink,  rociuind  iradicotomy. 

CO.\TKAI.\l)IC.\T|(INS    To    TK.\CI  i  111  ildM  ^■. 

There  are  no  contraindications  to  traciicolonn-. 


MOUTAMTN'    Ol'    'IkACII  I'.dToM  Y. 


The  mortality  ui  tracheotomy  must  be  distinguished  from  that 
of  the  lack  of  prom|)tness  in  [icrforming  it.  and  especially  from 
that  due  to  inetlicient  after-care.  \\  c  fre(|uently  save  life  when 
tile    p;iticnt    is    unconscious,    limji    and    relaxed,    with     ihe    res])iration 


588  TRACHKOTOMY. 

entirely  abolished,  and  the  pulse  nearly  or  quite  imperceptible.  In 
the  experience  of  all  of  us,  many  times  has  the  result  of  quick  work 
seemed  like  quickening  the  dead.  In  one  of  the  author's  cases  the  heart, 
as  well  as  the  lungs,  had  ceased  to  act,  the  pupils  wide  open  and  fixed, 
according  to  Dr.  Clarence  Ingram  and  Dr.  Thomas  T.  Kirk,  who  were 
watching  the  patient.  The  operation  shoulil  be  done  in  all  jiatients  ap- 
parently dead  of  asphyxia.  I'nder  local  anesthesia  and  at  the  proper 
time,  tracheotomy  should  be  free  from  dangers  of  shock,  hemorrhage, 
or  consecutive  broncho-pneumonia.  Between  the  skin  and  the  trachea, 
in  the  middle  line,  there  is  no  large  vessel,  and  no  important  structure. 
There  should  be  no  more  mortality  from  the  operation,  per  se,  than  from 
the  opening  of  superficial  abscesses  by  an  incision  of  equal  length.  The 
shortened  route,  with  consequent  deficiently  warmed,  moistened  and  fil- 
tered air,  does  not  seem  to  be  injurious  to  the  lower  air  passages.  Mor- 
tality during  tracheotomy  is  usually  caused  by  general  anesthesia.  Mor- 
tality after  tracheotomy  is  usually  due  to  want  of  j)roper  care  and 
watchfulness.  Xo  tracheotomic  case  should  draw  an  unwatched  breath 
so  long  as  his  larynx  is  tightly  stenosed. 

Of  4:72  tracheotomies  done  in  the  clinic  and  elsewhere  b\-  Dr.  Pat- 
terson and  the  author,  there  has  been  a  mortality  of  (I  (1.27  per  cent). 
This  includes  all  cases  that  died  from  any  cause  whatever  within  a  week 
of  the  operation.  These  statistics  show  that  the  ojieration  is  much  less 
dangerous  than  is  generally  supposed.  It  is  to  be  noted  that  in  many  of 
the  cases  the  operation  was  done  later  than  it  should  have  been,  and  if 
the  series  had  shown  even  a  ten  per  cent  mortality,  it  would  not  have 
changed  the  author's  opinion  that  the  operation  is  an  entirelv  safe  one 
when  performed  at  the  first  indication. 

INSTRf.MKNTS. 

For  a  tracheotomy  the  essentials  are  a  knife  and  a  pair  of  hands. 
Even  eyesight  is  not  essential,  and  the  author  twice  has  been  quite  suc- 
cessful in  a  dark  room  with  nothing  but  a  knife.  Such  performances, 
while  life-saving  and  justifiable  in  emergencies,  are  to  be  avoided,  when 
pos.sible,  by  early  operation  with  jiroper  preparation.  In  all  surgery'  it 
is  wise  to  have  the  armamentarivmi  as  simple  as  possible.  It  is  especially 
necessary  in  operations  which,  like  tracheotomy,  are,  in  some  instances, 
extremely  urgent.  The  following  list  contains  all  that  should  ever  be 
needed : 


TRACHEOTOMY. 


589 


TKACIIKOTOMY   INSTRUMENTS. 


Headlight. 
Scalpels. 
Retractors. 
Tenaculum. 
Trousseau  dilator. 
Hemostats. 
Scissors. 

Tracheal  cannula. 
Infiltration   solution. 


Curved  needles. 
Needle  holder. 
Tape   (good  white  linen j. 
Gauze  sponges. 
Sand  bag. 
Catgut  ligatures. 
Silk  worm  sutures. 
Tubing  for  o.xygen  tank. 
Hypodermic   syringe    for   local   an- 
esthesia. 

'J'raclh'otdiiiic  canntdac.  The  cannulae  of  the  shops  are  very  defect- 
ive and  have  been  the  cause  of  death  in  many  cases.  In  all  the  adult 
sizes  they  are  too  short  to  reach  the  trachea  after  the  reactionary  swell- 
ing has  reached  its  maximum,  'i'his  swelling,  in  some  instances,  doubles 
the  distance  from  the  trachea  to  the  skin,  and  thus  withdraws  the  cannula 
from  the  trachea.  The  thin  stream  of  air  hissing  through  the  tracheal 
incision  deludes  the  nurse  and  the  patient  slowly  sinks.  Such  cases  (Fig. 
441)  have  been  recorded  as  "edema  of  the  lungs"  or  "dyspnea  only  tem- 
porarily relieved  by  tracheotomy,"  etc.  Cases  of  compression  and  other 
forms  of  tracheal  stenosis  require  a  cannula  still  longer  and  in  some  in- 
stances it  must  reach  to  the  bifurcation  (  Fig.  .\.  VM  and  Fig.  44"-i).  -A 
fencstrum  in  a  cannula  is  a  great  mistake.  The  jjatient  can  get  plenty  of 
air  past  the  unfenestrated  cannula  and  tiie  latter  avoids  the  troublesome 
uK^-rations,  fniig.ations  ;ind  cicatricial  mischief  set  U])  liy  a  fenestruni; 
wiiicli,  moreover,  is  seldom  in  position  to  do  any  good.  Tapered  camuilae 
are  due  to  a  curifius  misunderstanding  of  physics.  To  overcome  the  defi- 
ciencies found  in  .-ill  the  canmilac  in  the  sho[)s,  the  author  has  had  made 
by  Messers  I'illing  a  full  set  of  cannulae  (1!,  b'ig.  l.'>!»)  of  sul'ticient 
length  to  reach  the  trachea  in  every  instance,  no  ni;ittcr  how  great  the 
swelling,  e\en  in  cases  of  JAuhvig's  angina.  Later  when  the  reactionary 
swelling  subsides,  the  space  between  the  shield  and  the  neck  is  taken  up 
Ijy  additional  dressiiigs  (Fig.  4  11  >,  ])rop])ing  the  shield  out  to  the  proper 
I)oint  so  that  the  imier  end  of  the  caiunila  does  not  turn  forward  and 
press  against  the  trachea.  This  e.xtra  length,  with  proper  curvature  en- 
ables the  operator  to  fit  the  tube  exactly  to  any  case,  and  in  no  instance 
is  the  cannula  accidentally  withdrawn  from  the  tr.iclie.a  with  consecjuent 
asphyxia  of  the  patient.  These  tubes  are  made  to  ilie  author's  scale 
(Fig.  440).  H  these  tubes  are  found  too  long,  the  chances  are  the  tra- 
cheotomy h;is  been  done  too  high.  I'or  stenosis  deep  down  beyond  the 
point  where  a  tr;icheotomy  wmnid  can  get  below  it,  the  long  cane-shaped 


590 


TRACHEOTO?.lY. 


caiinulae  shown  at  A,  Fig.  439  are  to  be  used.  With  tlie  aid  of  the 
bronchoscope  to  determine  the  condition,  no  patient  should  die  for  want 
of  air  as  long  as  he  has  the  lung  tissue  to  utilize  it.  These  long  can- 
nulae  may,  in  some  instances,  require  cutting  ofif  to  the  proper  length. 
Under  ordinary  circumstances,  they  should  never  touch  the  carina  at 
the  bifurcation  of  the  trachea,  though  in  some  instances  it  is  necessary 
to  extend  them  into  one  or  the  other  bronchus,  as  in  the  case  illustrated 
in  Fig.  405.  The  usefulness  of  these  cannulae  in  thymic  stenosis  has 
already  been  herein  illustrated  (Fig.  40T).  A  cane-shaped  cannula  com- 
pletely relieving  the  dyspnea  of  compressive  malignant  retrosternal  goitre 


Fig.  4,3g. — Autlior's  tracheotomic  cannulae.  A  shows  canc-shaped  cannula  for 
use  in  intrathorac'C  compressive  or  other  stenoses.  B  shows  fnll-curved  cannula 
for  regular  use.  Pilots  are  made  to  fit  the  outer  cannula;  the  inner  cannula  not 
being  inserted  until  after  withdrawal  of  tlie  pilot. 


is  shown  in  Fig.  442.  To  prevent  trauma  to  the  tracheal  cartilages  or 
to  the  walls  of  the  fistula,  as  well  as  to  facilitate  introduction  when  the 
fistula  tightens  from  cicatricial  contraction  ])i!ots  are  necessary  with  any 
kind  of  cannula.  It  is  unnecessary  to  have  the  pilots  fenestrated  and 
hollow,  because  the  introduction  of  the  cannula  involves  but  a  moment 
and  it  is  easy  for  the  patient  to  get  along  without  breathing,  or  e\en  to 
hold  his  breath,  for  such  a  brief  time. 

Some  patients  with  more  or  less  chronic  conditions  which  interfere 
with  inspiration,  l)Ut  lia\ing  expiration  free  and  easy,  can  be  relieved 
of  the  necessity  of  closing  the  tube  during  expiration  when  thev  wish  to 
speak-,  by  the  valve  cannula  of  DeSanti.     The  inspiration  is  through  the 


TRACIIKOTOMV. 


.■)!)| 


cannula  in  tlie  ordinary  way.  but  on  expiration  a  valve  closes  oft  the 
0|)enin<j  to  the  external  air  through  the  neck  and  thus  the  air  is  forced 
through  the  larynx,  which  the  patient  uses  for  phonation.  The  author 
prefers,  however,  the  finger  for  temporary  occlusion,  and  a  cork  for  pro- 
longed occlusion,  as  mentioned  in  conneclion  with  chronic  larvngeal 
stenosis. 

An  emergency  may  occur  away  from  home  when  a  tracheotomy  has 
to  be  done,  and  there  is  no  cannula  at  hand.  Under  such  circumstances, 
it  has  been   customary  to  recommend  the  suturing  of  the  edges  of  the 


INFANT 


JVtARi 


(-YflS 


1JY/J5 


5MALL  AnULT  f^OULJ 


Fir,.  440. — Scale  of  correct  size  and  ratliii.s  of  curvature  of  the  aiitlmr's  trachco- 
tomic  cannulae  for  the  various  ages. 


r-? 


Fig.  441. — Sclu-ma  sliowing  thick  pad  of  gauze  dressing,  filling  the  space,  A, 
and  used  to  Imld  out  the  author's  full-curved  cannula  when  too  long,  prior  to  reac- 
tionary swelling,  and  after  sul)sidence  of  the  latter.  .'\t  the  right  is  shown  the- man- 
ner in  whicli  the  ordinary  cannula  of  the  shops  permits  a  patient  to  aspliy.viate, 
though  siimc  air  is  licard  passing  througli  the  tracheal  opening,  H,  after  the  cannula 
has  hcen  partially  withdrawn  hy  swelling  of  the  tissues,  T. 


trachea  to  the  skin.  'Phis  is  (|uite  unreliable,  because  no  such  sutures  can 
be  relied  upon  to  hold  the  trachea  very  long.  .\  makeshift  canntila 
formed  by  slitting  one  end  of  a  short  piece  of  rublier  tubing  and  attaching 
strong  cord  to  each  half  of  the  slit  end,  m;iy  be  tiscd,  but  if  ilic  iiatient  is 
left  in  inexperienced  hands,  the  chances  are  that  he  will  asphyxiate  from 
an  accident  to  such  a  contrivance.  ( )f  course,  if  he  is  in  charge  of  anv- 
one  who  understands  spreading  the  tracheal  wound,  he  will  be  safe  if 
closely  watched;  but  the  .sooner  a  proper  cannula  is  obtained  the  better. 
No  hosi)ital  or  surgeon  should  be  so  jioorly  equipped  as  to  be  compelled 
to  resort   to  a  makeshift  so  hazardous  to  hninan   life,     Cannulae  should 


-,92 


TRACHEOTOMY. 


never  be  made  of  aluminum.  This  metal  is  corroded  by  boiling,  and  often 
by  wound  secretions.  It  loses  its  polish  quickly  and  soon  becomes  very 
rough.  Hard  rubber  is  very  objectionable  because  it  loses  shape  on  boil- 
ing, and  its  walls  are  so  thick  as  to  leave  too  little  lumen.  If  made  thin 
it  mav  break.  Soft  rubber  is  open  to  the  same  objection  and  besides  is 
very  irritating  to  the  wound.  Either  sterling  silver,  or  "German  silver" 
(neusilber)  plated  with  pure  silver  should  be  used. 

High  or  low  tracheotomy.       Which?     It  is  \ery   unfortunate   that 
there  ever  was  made  the  distinction  between  operations  above  and  those 


Fig.  442. — Radiograph  of  a  man  of  fifty  years  with  a  substernal  goitrous  com- 
pression stenosis,  the  dyspnea  of  which  was  completely  relieved  by  the  author's 
cane-shaped  tracheotomic  cannula. 

below  the  isthmus  of  the  thyroid  gland.  L'sually  three  separate  oper- 
ations are  described  under  tracheotomy :  namely,  intercricothyroidotomy, 
high  tracheotomy,  low  tracheotomy.  Intercricothyroidotomy  should  never 
be  done,  unless  the  operator  does  not  feel  competent  to  do  a  quick  tra- 
cheotomy below  the  cricoid.  Obviously,  anything  is  justifiable  to  save 
life,  but  the  risk  of  subsecjuent  stenotic  troubles  is  verv  much  greater 
after  a  stab  operation  through  the  cricothyroid  membrane.  ( Inly  a  small 
cannula  can  be  inserted.  To  enlarge  the  incision  the  cricoid  must  be  cut 
which  is  a  thing  to  be  avoided  when  possible.  I'urtliermorc,  one  mav  not 
know  the  lower  limits  of  a  stenosis,  which  may  be  too  low  to  be  relieved 


TKAcnKiiroMV.  593 

li\-  the  cricotliyroid  operation.  It  is  unfortunate  that  any  distinction  has 
ever  been  made  between  high  and  low  tracheotomy  because  most  oper- 
ators when  a  low  tracheeotomy  is  decided  upon  proceed  to  make  a  low 
incision.  No  wonder  they  consider  it  a  difficult  operation.  A  low  in- 
cision means  a  short  incision  and  consequently  they  are  working  at  a 
great  disadvantage  down  in  a  deep  narrow  wound  full  of  blood.  If  there 
was  no  division  into  high  and  low  operations  the  trachea  would  always 
be  exposed  high  where  it  is  superficial  and  followed  down  to  the  point 
at  which  it  is  decided  to  open  it.  The  inexperienced  operator  will  find 
it  easy  to  lay  bare  ".\dam's  apple."  He  should  not  incise  it.  but  simply 
follow  it  down  until  he  comes  to  the  first  tracheal  rings.  If  he  makes 
a  long  external  incision,  allowing  himself  plenty  of  room  for  the  separa- 
tion of  the  tissues,  the  trachea  can  be  very  tpnckly  followed  from  above 
downward,  and  incised  at  an\'  point  desired.  If  the  thyroid  gland  is  very 
much  hypertrophied,  it  may  be  necessary  in  some  instances  to  cut  through 
the  isthmus,  retracting  each  lobe,  though  ordinarily  this  is  not  required, 
because  the  isthmus  is  freely  movable  upward  or  downward,  and  room 
enough  can  be  obtained  for  the  insertion  of  the  cannula  either  above  or 
below.  Cricothyroidotomy  should  not  be  the  operation  of  choice.  It 
or  anything  else  is  justifiable  for  the  saving  of  life  but  cutting  through 
the  cricothyroid  membrane  means  invasion  of  the  subglottic  region  of 
the  larynx  by  inflammatory  reaction,  and  this  is  almost  certain  to  be 
followed  by  more  or  less  laryngeal  stenosis  and  perichondritis.  Dr. 
Patterson  and  the  author  have  noticed  that  a  very  large  proportion  of 
the  cases  coming  to  our  attention  for  the  relief  of  post  tracheotomic  laryn- 
geal stenosis  has  been  in  the  cases  where  the  operation  has  been  done 
through  the  cricothyroid  membrane.  Every  one  of  these  cases  was  an 
emergency  operation  and  saved  the  patient's  life,  many  of  them  being 
done  practically  in  the  dark  and  were  perfectly  justifiable,  yet  the  author 
deems  it  his  duty  to  call  attention  to  this  ni;Utcr  because  of  the  prevalent 
ojiinion  among  laryiigologists  and  general  surgeons  that  the  high  tr;icheot- 
omy,  even  as  high  as  the  cricothyroid  membrane,  is  an  o|ierati(in  of 
choice  when  quick  work  is  needed.  Division  of  the  tluniid  gland  is  a 
trifling  matter  and  should  in  no  case  influence  the  operator  to  make  the 
mistake  of  doing  tracheotomy  higher  than  the  second  ring  of  the  trachea. 
W  lien  done  for  subglottic  edema,  tlie  opening  should  he  made  below  the 
third  ring  of  the  trachea,  not  but  that  a  higher  tracheotomy  with  a  prop- 
erly fitting  cannula  would  reliive  the  dyspnea,  but  the  reaction  around 
the  tube,  phis  the  subglottic  inllainmation  already  present,  is  verv  apt  to 
lead  to  stenosis.  Particularly  pernicious  is  it  to  incise  the  cricoid  car- 
tilage.    Stenosis  is  almost  certain  to  follow. 


5i)4 


TRACHEOTOMY. 


The  author  has  been  called  upon  to  do  a  tracheotomy  in  a  case  of 
laryngoptosis  in  a  man  .-)4  years  of  age  affected  with  cancer  of  the  larynx. 
As  almost  the  entire  thyroid  cartilage  was  below  the  sternal  notch,  as 
shown  in  another  case  (Fig.  404),  a  subhyoid  pharyngotomy  was  done 
and  a  cane-shaped  tube,  Fig.  439,  was  inserted  down  through  the  larynx 
into  the  trachea.  When  the  cannula  was  removed  for  cleaning,  the 
growth  would  push  out  and  close  up  the  lumen  within  about  one  minute's 
time,  but  by  having  two  cannulae,  as  is  our  regular  custom,  and  with  the 
obturator,  with  which  these  tubes  are  fitted,  the  nurse  could  very  readily 
make  the  change.  All  forms  of  trapdoor,  transverse  and  other  special 
plans  for  the  tracheal  incision  are  often  followed  by  stenosis  ( Fig.  12, 
Plate  I)   especially  if  the  tube  is  worn  for  a  long  time. 


s 

Fig.  443. — Schema  showing  the  necessity  for  avoiding  making  two  tracheotomic 
openings  close  together.  A  represents  the  old  tracheotomic  wound  and  B  the  new 
one,  leaving  one  or  two  rings  in  the  island  of  cartilage,  C,  undivided.  W  hen  a 
tracheotomic  cannula,  D,  is  inserted  the  island,  E,  is  pressed  back  into  the  lumen 
of  the  trachea,  T,  resulting  eventually  in  a  permanent  stenosis  as  shown  in  the 
schematic  endoscopic  view,  H,  which  represents  the  view  down  the  trachea  at  the 
point,  E,  when  the  tracheotomic  cannula  was  temporarily  removed  for  oral 
tracheoscopy. 


When  necessary  to  do  a  tracheotomy  below  one  not  already  healed, 
it  is  necessary  to  work  without  leaving  an  island  of  cartilage  between  the 
old  and  the  new  wound  as  will  be  understood  by  reference  to  Fig.  443. 
It  is  not  that  the  island  of  cartilage  in  this  instance  would  be  apt  to  die, 
but  a  ring  or  two  of  cartilage  has  very  little  resistance  to  pressure  and 
one  or  two  rings  will  be  easily  pressed  in  by  the  cannula  as  shown  in  the 
illustration,  and  to  become  fixed  there  b\  inflammatory  tissue  as  hap- 
pened in  the  case  from  which  the  drawings  were  made. 

When  a  tracheotomy  is  urgently  needed  before  a  diagnosis  has  been 
made  in  a  case  suspected  of  being  luetic,  cancerous  or  tuberculous,  it  is 
best  to  commence  the  incision  high  up  so  that  the  thyroid  cartilage  can  be 


■|RACIli;oTl)MY.  595 

exposetl  and  cxaniined.  \ery  often  in  laryngeal  lues  ami  tuberculosis 
that  has  progressed  so  far  as  to  need  tracheotomy,  periclmndrial  involve- 
ment of  a  plainly  inflammatory  character  is  manifest. 

Asepsis.  In  emergencies,  the  saving  of  life  may  demand  the  dis- 
regard of  all  the  rules  of  modern  surgery,  not  only  as  to  the  preparation 
of  the  patient  but  even  as  to  the  sterilization  of  a  knife  and  the  hands. 
It  has  happened  to  every  surgeon  not  to  see  the  patient  until  alter  the 
breathing  has  ceased.  Except  under  such  extreme  circumstances  all  the 
asej)tic  precautions  should  be  carried  out  with  the  same  care  as  if  the 
brain.  ab<lomen  or  thorax  were  to  be  ojiened.  Such  a  stalcmenl  may  seem 
suiiertluous  to  the  surgeon,  who,  of  course,  expects  to  do  all  his  work 
thus,  r.ut  it  is  necessary  to  be  especially  disciplinary,  as  there  is  a  nat- 
ural tendency  u]ion  the  [lart  of  nurses,  internes  and  (ithers  to  permit 
laxity  because  the  patient  coughs  through  the  wound  and.  in  some  in- 
stances, the  surgeon  must  work  through  both  mouth  and  wound.  It 
must  be  remembered,  however,  that  the  patient  is  more  or  less  immune 
to  the  organisms  he  himself  harbors,  while  he  may  be  extremely  suscep- 
tible to  organisms,  nominally  and  morphologically  the  same  introduced 
from  another  source.  Rubber  tubing  of  proper  size  for  the  oxygen 
tank  should  be  sterilized  with  the  instruinents  and  one  end  attached  by 
tlie  unsterile  nurse  to  the  tank.  Then  the  tank  should  be  covered  with 
wet  sterile  towels  so  that  it  can  be  handled  by  the  sterile  assistant.  All 
confusion  and  sejitic  risks  are  thus  a\c)ided  when  oxygen  is  needed  in  a 
hurry.  The  autlior's  tank  holder  illustrated  nn  ;i  prc\inus  page,  is  a  life- 
saving  convenience. 

Preparation  of  the  patient.  All  the  i>rccaiUions  mentioned  in  Chap- 
ter III  must  be  carried  out,  except  in  great  emergencies.  In  addition, 
it  would  he  wise  to  extract  carious  teeth,  or  have  them  filled  and  to  com- 
bat oral  sepsis  in  all  the  ways  mentioned.  If  any  operation  on  the  larvnx 
is  contemplated,  it  becomes  absolutely  imperative  to  get  rid  of  every  dead 
tooth  or  root  and  to  clean  up  and  till  every  spot  of  caries.  The  face  and 
front  of  the  neck  should  be  shaven  in  case  of  a  man.  Tlu'  skin  of  the 
neck  and  chin  should  be  prepared  by  iodin  solution,  used  on  the  dry  skin, 
in  the  case  of  adults.  The  more  tender  skin  of  children  should  be 
scrubbed  with  a  gauze  sponge,  using  soap  and  water,  Idlhiwcd  li\  dilute 
alcohol.  It  is  especially  necessary  to  avoid  causing  a  dermatitis  bv  a  too 
irritant  preparatinn  of  the  skin.  In  surrounding  the  field  with  towels, 
the  upper  i)an  uf  the  face  should  be  left  bare  for  observation. 

Position  of  the  patient  and  assistants  for  tracheotomy,  and  for  arti- 
ficial respiration.  The  jialient  should  be  recumbent.  The  head  of  the 
table  should  be  lower  than  the  fdot.  The  neck  of  the  jialient  should  be 
extended  and  rendered  prdmint'ni  by  a  sand  bai;  under  the  shoulders  anil 


5d(i  TRACHEOTOMY. 

neck,  not  extending  further  toward  the  occiput  than  the  prominent  sev- 
enth cervical  vertebra.  If  this  extreme  extension  too  greatly  increases 
dyspnea,  the  sand  bag  may  be  moved  a  little  more  toward  the  head.  One 
assistant  or  nurse  should  kneel  at  the  head  of  the  table  so  as  to  be  out  of 
the  way  while  attending  strictly  to  the  very  important  duty  of  holding 
the  patient's  head  exactly  in  the  middle  line  without  permitting  rota- 
tion. The  operator  should  be  on  the  patient's  right,  the  first  assistant 
in  charge  of  sponges  and  hemostats,  on  the  left ;  the  second  assistant, 
who  holds"  retractors,  stands  at  the  patient's  head,  sharing  the  space  with 
the  nurse  who  kneels.  The  jiatient,  if  a  child,  may  be  wrapped  in  a 
sheet  to  restrain  the  arms  and  legs,  but  it  is  far  preferable  to  have  both 
legs  held  by  a  nurse  and  both  arms  held  by  a  physician  who  can  watch 
the  pulse  at  the  same  time.  If  breathing  ceases  the  assistant  at  the  head 
of  the  table  takes  the  two  elbows  of  the  patient  for  calm  orderly  artificial 
respiration,  20  times  a  minute,  compressing  the  chest  with  the  patient's 
elbows  at  the  end  of  the  down  stroke,  raising  the  ribs  by  the  pull  on  the 
elbows  at  the  end  of  the  up  stroke.  Thus  done,  the  arm  movements  do 
not  interfere  with  the  oxygen  tubing  held  by  the  assistant  at  the  side 
opposite  the  operator. 

Anesthesia  for  tracheotom\<  should  be  local.  General  anesthesia  is 
not  only  unnecessary  but  introduces  an  enormous  element  of  danger  out 
of  all  proportion  to  the  anesthetic  risk  in  the  general  run  of  surgical 
work.  The  danger  mav  be  primary  from  asphyxia  or  secondary  from 
asijiration  of  infected  blood,  pus  or  secretions.  The  cough  reflex  is  the 
watch-dog  of  the  lung,  and  when  the  trachea  is  to  be  opened  should  be 
preserved  or  stimulated,  rather  than  drugged  asleep.  Aside  from  this, 
general  anesthesia,  strange  as  it  may  seem,  often  renders  our  technic 
more  hasty  and  careless  than  local  anesthesia,  for  the  following  reasons : 
When  tracheotomy  is  decided  upon,  there  is  usually  sufficient  dyspnea 
to  demand  some  voluntary  use  of  the  accessory  muscles  of  respiration. 
As  complete  anesthesia  approaches,  this  voluntary  action  ceases,  cyanosis 
increases  until  the  respiratory  center  is  paralyzed  from  over-stimulation, 
and  the  patieiit  makes  no  further  breathing  effort.  He  never  will  make 
another  breathing  effort  unless  the  trachea  is  opened  widely  and  on  the 
instant.  For  with  an  obstructed  larynx,  artificial  respiration  is  never 
efticient  for  complete  o.xygenation  of  the  blood.  The  trachea  under  these 
circumstances  is  by  some  operators  opened  by  a  stab,  rather  than  by  an 
incision,  and  it  is  small  wonder  if  the  percentage  of  mortality  is  almost 
as  high  as  of  stab  wounds,  inflicted  with  homicidal  intent.  In  the  hands 
of  the  most  skilful  and  exjierienced,  the  incision  may  be  badly  placed : 
(unless  the  author's  method  is  followed)  ;  in  the  hands  of  the  unskilled 
or  tlie  excitable,   serious  accidents   have  ocoirred,   such   as   the  opening 


TR.\CUKOT(JMV. 


597 


of  the  (.■sophagus  or  a  large  vessel.  A  collection  of  tracheotomy  speci- 
mens shows  inciiions  at  all  sorts  of  positions  and  angles  (Fig.  44t). 
Tliere  is  no  time  for  hemostasia ;  the  opening  is  made  at  the  bottom 
of  a  pool  of  blood,  and  the  first  inspiration  necessarily  aspirates  clots,  and 
possibly  pus,  or  infectious  secretions,  into  the  bronchioles,  where  it  re- 
mains, because  the  cough  reflex  is  absolutely  abolished  by  the  cumulative 
action  of  general  anesthesia,  deep  cyanosis,  and  shock.  There  is,  there- 
fore, a  large  mortality  from  shock,  hemorrhage,  sepsis,  and  broncho- 
pneumonia. How  prone  the  profession  is  to  underrate  the  dangers  of 
general  anesthesia  is  shown  by  the  continued  succession  of  case  reports 


Fk;.   444. — Schematic    illustration    of    faulty    incisions    of    the    traclu-a    (hie    to 
faulty  tfchnic.      (From  observations  of  Laurens). 


ill  which  rcs]iirati(in  has  ceased  on  the  talilc  and  a  stab  operaliim  is  dime. 
(  )iir  general  conception  of  the  operation  is  a  composite  picture  of  many 
such  instances,  because  we  are  all  disjjosed  to  defer  it  until  dyspnea  and 
cyanosis  are  extreme.  Particularly  fatal  is  the  common  error,  permitted 
by  nearly  every  surgeon,  of  starting  tracheotomy  without  anesthesia  and 
then  giving  the  anesthetic  after  the  patient  has  manifested  evidences  of 
pain.  The  administration  of  ether,  or  still  worse,  chloroform,  after  the 
subject  has  suffered  for  sometime,  will  hasten  dangerous  or  fatal  apnea. 
If  morphine  also  has  previously  been  given,  we  have  a  combination 
peculiarly  svnergistic  in  killing  the  patient.  In  the  dog.  bronchoscopic 
oxygen  insufflation  has  maintained  life  willi  ;i  total  absence  of  respiratory 
movements  for  as  long  as  IS  mintites.  when  res]>tratory  movements  were 
resumed.       With  the  human   being,   however,   the  operator    will   prefer 


.-.98 


TRACHKOTOMY. 


to  institute  artificial  respiratory  movements  rather  than  wait  for  tliem 
to  be  spontaneously  resumed.  In  most  instances,  also,  inasmuch  as 
tracheotomy  is  to  be  done  anyway,  the  surgeon,  will  prefer  the  insuf- 
flation of  oxygen  into  the  tracheal  wound,  and  the  addition  of  a  few 
nitrite  of  amyl  "pearls"  to  the  insufflated  vapor  will  save  life. 

The  foregoing  comments  on  respiratorv  arrest  and  its  treatment  arc 
made  here,  under  the  heading  of  anesthesia,  in  order  to  emphasize  the 


Fig.  445. — Schema  illustrating  iiitrademiatic  infiltration  anesthesia  for  tra- 
cheotomy. The  infiltration  is  between  the  lajers  of  the  skin,  not  under  the  skin. 
The  infiltration  needle,  at  H,  is  in  the  position  of  making  the  first  injection.  The 
needle  is  withdrawn  and  inserted  at  the  upper  border  of  the  white  wheal  made 
by  the  first  injection.  Then  the  needle  is  withdrawn  again  and  inserted  at  the 
upper  border  of  the  second  wheal,  and  so  on  upward  until  the  region  of  the 
thyroid  cartilage  is  reached.  The  full  length  of  the  incision  is  thus  anesthetized, 
with  no  pain  whatever  except  the  single  prick  of  the  first  injection.  The  reinser- 
tions  are  at  the  upper  edge  of  the  anesthetized  area  each  time.  If  now  it  is  de- 
sired to  infiltrate  the  deeper  tissues  at  B,  one  or  two  insertions  through  the  anes- 
thetized lines  may  be  made  for  deep  injection.  Deep  injections  are  unnecessary, 
however,  as  the  subdermal  tissues  are  not  sensitive. 


too  often  unrecognized  fact  that  it  is  usually  the  attempt  at  general  anes- 
thesia that  precipitates  apnea. 

Not  only  is  local  intihratioii  anesthesia  safer  but  it  is  much  i|uicker 
and  less  troublesome.  Not  more  than  a  minute  is  required  for  the  in- 
jection and  the  operation  can  follow  immediately. 

Local  anesthesia  for  tracheotomy.  The  solution  should  contain  a 
niimite  quantity  of  cocaine.  Salt  solution  alone  will  cause  slight  anesthe- 
sia, but  the  addition  of  cocaine,  no  matter  how  little,  obtunds  the  nerve 


TRACHl-OTOMV.  599 

ending  l)etter  than  the  pressure  of  salt  solution  alone.  In  the  author's 
clinic,  a  one-tenth  of  one  per  cent  cocaine  solution  is  used.  The  salt  solu- 
tion is  sterile  and  cocaine  tablets,  which  are  kept  constantl}-  in  formalde- 
liyd  \apiir.  are  added  just  before  operation,  the  solution  always  being 
freshly  prepared.  It  is  essential  that  the  injection  he  intradermatic,  not 
hypodermatic.  The  method  will  he  understood  by  reference  to  the 
schema,  Fig.  4-1 -"i.  'I'he  author  has  in  a  great  many  instances  dispensed 
with  even  the  local  anesthesia  in  patieiUs  that  were  not  unconscious.  The 
pain  was  said  by  the  patient  to  be  trifling,  as  in  the  following  instance : 
In  ,1  tracheotomy  done  for  ])ost-typhoid  laryngeal  perichondritis,  at  the 
Allegheny  General  Hospital,  upon  a  patient  referred  by  Dr.  Mc- 
Naugher,  the  operation  required  '^2  seconds  by  the  watch  and  was  done 
without  any  anesthesia  whatever,  general  or  local.  The  patient,  a  woman 
of  thirty  \ears,  said  ■"ouch"  twice,  and  stated  afterwards  that  the 
operation  was  no  more  painful  than  the  accidental  pricking  of  one's 
finger  by  a  pin. 

.  hicstheticing  a  iracheotoiniccd  patient.  No  hesitation  need  be 
felt  in  anesthetizing  a  tracheotomized  jiatient  so  far  as  the  tracheotomic 
wound  is  concerned.  Such  patients  are  far  safer  than  one  not  tracheo- 
tomized, and  there  is  no  trouble  with  the  tongue  or  the  tissues  attached 
to  the  hyoid  bone  falling  backward  and  downward,  obstructing  breathing. 
Tliey  lal;e  the  anesthetic  quietly.  It  has  been  necessary  many  times 
for  Dr.  Patterson  to  remove  tonsils  from  patients  under  treatment  in  the 
clinic  for  laryngeal  stenosis.  In  every  instance  the  patient  went  under 
ether  quietly  and  was  kept  fully  under  until  the  operation  was  completed, 
all  vessels  twisted  and  oozing  stopped.  The  technic  is  simple.  A  fold 
of  gauze  is  laid  (Aer  the  tracheotomic  cannula  and,  if  the  laryngeal 
stenosis  is  not  complete,  another  over  the  mouth.  The  ether  is  dropped 
upon  both  pieces  so  th;it  no  matter  which  way  air  is  taken  in,  it  carries 
the  ether  \apor  with  it.  It  is  necessary  before  starting  to  see  that  a 
good  stout  ta])e  is  secvu-ely  attached  to  the  cannula  and  tied  back  of  the 
neck  in  the  regular  wa\'.  <  )ne  assistant  or  nurse  trained  in  tracheal 
work  should  be  stationed  to  gi\e  undixided  attention  to  the  cannula  and 
secretions  coming  from  it.  A  Trousseau  dilator  should  be  at  her  hand 
should  anything  happiMi  tn  the  cnuuila.  If  insufllation  anesthesia  is 
to  be  used,  in  a  tracheotomized  case,  it  is  usually  preferal)le  to  in- 
sert the  catheter  through  the  larynx  provided  there  is  a  widely  open 
wnund  for  esca|)e.  I 're>iun,i]ily  llir  l.irnyx  is  stenosed,  but,  it  not,  of 
course  insulllatinn  tlr.nugh  the  laryn.x  is  the  same  as  if  no  tracheotomy 
had   been   done. 

Technic.  The  classical  descrii)tions  of  the  ste|)S  in  tracheiitnniy  are 
verv    f;uilt\'.      The    dixisinn    n\    the   tissues   after   identilicaticm,    la\er    bv 


coo  TRACHKOTOMV. 

layer,  on  a  grooved  director  is  a  needless,  time  wasting  encumbrance. 
The  skin  and  subcutaneous  cellular  tissue  should  be  cut  at  the  first  stroke 
of  the  knife.  This  incision  should  be  in  the  median  line  and  should  ex- 
tend from  the  thyroid  notch  to  the  suprasternal  notch.  The  deeper  tis- 
sues are  then  divided  by  shallow  incisions,  the  vessels  being  drawn  aside 
with  retractors  held  by  an  assistant ;  or  seized  before  division  as  may 
seem  best.  The  back  of  the  point  of  the  knife  may  be  used  or  a  blunt 
dissector  if  desired.  The  trachea  is  to  be  bared  above  the  cricoid  first  and 
then  followed  downward.  When  the  entire  trachea  from  the  cricoid  to 
about  the  fifth  ring  has  been  bared  of  overlying  tissues,  the  thyroid  being 
retracted  upward  or  downward,  all  bleeding  having  been  arrested,  the 
trachea  may  be  incised  at  the  desired  location,  hi  making  the  tracheal 
incision  three  things  must  lie  carefully  guarded  against. 

First,  incising  the  posterior  tracheal  wall  by  allowing  the  knife  to  go 
in  so  deeply  as  to  cross  the  trachea  and  cut  the  posterior  tracheo-eso- 
phageal  "party-wall."  This  is  especially  likely  to  happen  during  the 
forward  protrusion  of  the  posterior  w'all  during  cough,  and  in  the  small 
trachea  of  infants. 

Second,  a  badly  directed  incision  (B,  Fig.  444.). 
Third,  a  double  incision,  from  making  two  incisions  instead  of  one. 
(A,  Fig.  444).  If  the  first  incision  is  not  long  enough,  the  knife  should 
be  accurately  inserted  in  the  first  incision  and  this  incision  elongated. 
The  island  of  cartilage  between  two  incisions,  as  at  A,  Fig.  444,  is  al- 
most certain  to  die  and  even  if  it  does  not,  stenosis  is  apt  to  follow,  from 
displacement  of  the  island  and  cicatricial  contractions  of  the  tracheal 
wall.  Badly  directed  incisions  are  most  apt  to  occur  from  a  twisted  po- 
sition of  the  patient's  head  distorting  the  position  of  the  trachea,  or  with 
those  operators  who  do  not  follow  the  author's  two-step  finger-guided 
method  of  emergency  tracheotomy. 

Whatever  be  the  plan  of  operation,  one  very  common  error  must 
be  avoided.  Almost  every  operator  is  tempted  to  terminate  his  incision 
of  the  trachea  just  as  soon  as  he  hears  a  hiss  of  air.  The  Trousseau  di- 
lator or  a  hemostat  is  then  inserted  through  a  very  small  wound,  and, 
when  spread,  it  rips  the  trachea  open  sidewise,  tearing  the  interannular 
membrane.  It  is  far  better  to  feel  the  knife  go  through  three  separate 
rings,  each  of  which  will  communicate  a  separate  and  distinct  sensation 
to  the  finger,  and  they  can  be  easily  counted  though  not  seen.  This  in- 
sures a  sufficiently  long  incision  for  the  easy  insertion  of  the  cannula 
without  tearing  the  interannular  membrane.  For  the  elongation  of  an 
insufficient  tracheal  incision  tin-  probe-pointed  bistoury  is  safest,  but 
with  care  to  avoid  deep  insertion  the  ordinary  scalpel  is  safe.  When 
there  is  time,  it  is,  of  course,  wise  to  stop  all  bleeding,  ligating  when  ne- 


TRACHIiOTOM^-.  (UH 

cessary,  and  to  lia\(.-  the  W'unil  in-rlectly  dry  ami  hcmostats  removed 
before  the  tracliea  is  opened.  Having  incised  the  trachea  the  Trousseau 
dilator  is  gently  used  to  spread  the  lips  of  the  tracheal  incision.  Great 
care  is  needed  to  a\oid  damaging  the  annular  cartilages  or  the  interan- 
nular  membrane.  Either  accident  may  cause  chondrial  necrosis  and  sub- 
sequent stenosis.  If  the  patient  has  been  very  dyspneic.  he  will  take  a 
deep  breath,  as  soon  as  the  trachea  is  opened,  and  then  will  cease  breath- 
ing for  a  few  seconds.  This  in  (mr  clinic  is  called  the  "tracheotomic 
sigh  of  relief"  and  is  present  in  almost  every  previously  dyspneic  case, 
especiall\-  in  children,  and  is,  really,  just  a  moment  of  rest  and  relaxation 
after  the  prolonged  fight  for  air.  This  apnea  is  readily  distinguished 
from  respiratory  arrest  of  apnea  vera  by  the  difi'erence  in  color  of  the 
patient's  cheeks.  If  there  has  been  much  glottic  C)bstruction  a  quantity 
of  pus  may  escape.  After  the  patient  has  had  a  few  deep  inspirations, 
the  cannula  is  inserted  and  the  wound  dressed.  The  upper  and  lower 
ends  of  the  incision  may  be  drawn  together  with  a  few  stitches,  but  as  a 
rule  the  incision  sIkjuWI  not  be  closed  close  to  the  cannula.  Ijecause  of  the 
likelihood  of  making  a  false  passage  when  the  cannula  is  changed.  For 
this  ])urpose,  a  large  open  wound  in  which  the  trachea  can  lie  jiromptly 
located  and  its  incision  spread  is  imperative.  It  is  necessarv  for  safety 
as  well  as  to  prexent  trauma  to  the  cartilages.  Patients  have  been 
known  to  die  "unrelieved  l)y  tracheotomy"  because  the  interne  inserted 
the  cannula  down  between  the  layers  of  the  tissues  of  the  neck  where  it 
was  left  under  the  su]iiJOsition  that  it  was  in  the  trachea.  Injury  of  the 
cartilages  or  their  perichondrium  may  result  from  forcing  in  a  cannula. 
The  old  advice  to  suture  the  trachea  to  the  skin  in  tracheotomies  for  for- 
eign bodies,  instead  of  using  a  cannula,  in  the  hope  of  bechic  expulsion 
of  the  foreign  body  has  had  a  most  pernicious  influence,  in  as  much  as  it 
has  led  to  the  habit  in  various  cases  of  such  stitching  which  is  a  frequent 
source  of  tracheal  stenosis  because  of  the  damage  done  to  the  interannular 
membrane  and  to  the  perichondrinn-.  of  the  tracheal  rings,  i  'nly  in  the 
operation  of  laryngostomy  is  such  a  procedure  justifiable  and  even  here 
the  author  has  found  it  best  to  dis])ense  with  it  as  unnecessary.  Many 
operators  ele\ate  the  trachea  with  a  tenaculum  before  incising  it.  In  the 
deliberate  operation  with  a  dry  wound,  in  which  the  trachea  can  be  seen, 
this  is  an  excellent  way  to  fix  and  elevate  llu-  trachea  for  the  incision. 
The  author,  however,  prefers  to  incise  the  undisturbed  trachea. 

.\s  mentioned  in  connection  with  some  of  the  cases  a  bronchoscope 
in  the  trachea  greatly  facilitates  a  tracheotomy  and,  while  the  author 
would  not  advise  a  preliminary  lironchosco|)v  as  a  routine  procedure, 
yet  in  all  cases  where  bronchoscopy  is  done  for  conditions  rei|uiring  im- 
mediate tracheotonu'  the  bronclioscojie  sliould  be  k'ft  in  jiosition  .and  cut 


G02  TRACHEOTOMY. 

down  upon  from  the  outside.  Not  only  does  the  bronchoscope  serve  as 
a  stalT  for  guidance,  holding  the  trachea  up  clear  of  the  lateral  danger 
zone,  but  it  also  insures  plenty  of  air  for  the  patient  with  admixture  of 
o.xvgen  if  desired  so  that  the  tracheotomy  can  proceed  in  an  orderly  way 
with  thorough  hemostasis  before  the  trachea  is  opened. 

In  tracheotomizing  patients  wearing  an  intubation  tube,  it  is  better 
to  substitute  a  bronchoscope  for  the  intubation  tube  before  commencing 
the  tracheotomy. 


KiG.  446. — Schema  of  practical  gross  anatomy  to  be  memorized  lor  emergency 
tracheotomy.  The  middle  line  is  the  safety  line,  the  higher  the  wider.  Below,  the 
sufety  line  narrows  to  the  vanishing  point  VP.  The  upper  limit  of  the  safety  line 
is  the  thyroid  notch  nntil  the  trachea  is  bared,  when  the  limit  falls  below  the  first 
tracheal  ring.  In  practice  the  two  dark  danger  lines  are  pushed  back  with  the  left 
thumb  and  middle  finger  as  shown  in  Fig.  447,  thus  throwing  the  safety  line  into 
prominence. 

Emergency  tracheotomy.  The  stabbing  of  the  cricothyroid  mem- 
brane, or  an  attempted  stabbing  of  the  trachea,  so  long  taught  as  an 
emergency  tracheotomy  is  a  mistake.  The  author  has  always  taught  his 
"two-stage,  finger-guided''  method  as  safer,  quicker,  more  efticient  and 
not  likely  to  be  followed  by  stenosis.  To  execute  this  promptly,  re- 
quires the  operator  to  forget  his  te.xt-book  anatomy  and  memorize  the 
schema.  Fig.  4-l().  All  of  the  important  vessels  and  nerves  are  at  the 
sides  of  the  trachea.  The  thumb  of  the  left  hand  pushes  back  the  ves- 
sels and  nerves  on  the  patient's  right  and  the  middle  finger  of  the  same 


TRACHKOTOMV. 


603 


hand  pushes  back  the  left  side  vessels  and  nerves.  (Fig.  447).  The 
purpose  of  using  the  middle  finger  is  to  leave  the  left  index  free  for  its 
duties  in  the  second  stage.  The  pressure  backward  forces  the  center 
safetv  line  into  prominence.  Xow  a  long  incision  is  made  from  the 
thyroid  notch  almost  to  the  sternal  notch,  and  deep  enough  to  reach  the 
trachea.     This  completes  the  first  stage. 


\ 


IL 


\ 


\ 


V 


V 


S\tTXVO 


V'- ' 


Fic.  447. — Schema  showing  the  author's  tiK'thod  of  rapid  traclieotomy.  First 
stage.  The  hands  are  drawn  ungloved  for  the  sake  of  clearness.  The  upper  hand  is 
the  left,  of  which  the  middle  finger  (M)  and  the  thumb  are  used  to  repress  the 
sterno-cleido-mastoid  muscles,  the  linger  and  thumb  being  close  to  the  trachea  in 
order  to  press  backward  out  of  the  way  the  carotid  arteries  and  the  jugular  vein. 
This  throws  the  trachea  forward  into  prominence,  and  one  deep  slashing  cut  will 
incise  all  of  the  soft  tissues  down  to  the  trachea. 


Second  stage.  The  entire  wound  is  full  of  blood  and  the  trachea 
cannot  be  seen  biU  the  trachea  is  to  be  found  very  reailily  by  the  tip  of 
the  index  finger  which  detects  the  ridges  of  the  tracheal  rings  feeling 
like  a  wash  board.  The  left  index  is  moved  over  a  little  bil  t(i  the  pa- 
tient's left  side  in  order  that  the  knife  shall  come  precisely  in  the  middle 
of  the  trachea,  and  the  trachea  is  steadied  by  the  left  index  so  that  the 
incision  can  be  made  (jtute  accurately  in  the  middle  line,  notwithstanding 


G04  TRACHEOTOMY. 

it  lies  buried  at  the  bottom  of  a  pool  of  blood.  The  head  of  the  table 
should  he  lowered,  just  as  soon  as  the  incision  in  the  trachea  is  com- 
pleted and  a  hemostat  or  the  Trousseau  dilator,  if  it  be  at  hand,  is  used 
to  spread  the  lips  of  the  tracheal  wound,  then  the  patient  is  turned  over 
on  the  side,  provided  the  patient  is  breathing  freely,  in  order  that  the 
blood  may  run  away  from  the  wound  and  less  of  it  may  be  aspirated. 
In  cases,  however,  where  respiration  has  ceased,  it  is  necessary  to  keep 
the  patient  on  the  back  so  that  efficient  artificial  respiration  may  be  kept 


Fig.  448. — Illustrating  the  author's  method  of  quick  tracheotomy.  Second 
stage.  The  fingers  are  drawn  ungloved  for  the  <;ake  of  clearness.  In  operating; 
the  whole  wound  is  full  of  blood,  and  the  rings  of  the  trachea  are  felt  with  the  left 
index  which  is  then  moved  slightly  to  the  operator's  left,  while  the  knife  is  slid 
down  along  the  left  index  to  exactlv  the  middle  line  when  the  trachea  is  incised. 


up.  In  doing  a  tracheotomy  after  respiration  has  ceased,  it  must  be  re- 
membered there  will  be  no  hissing  in  or  out  of  air.  Strange  as  it  may 
seem,  many  an  operator  has  been  misled  into  thinking  he  has  not  opened 
the  trachea  by  the  absence  of  this  sound  which  is  so  reliable  if  the  pa- 
tient is  breathing.  During  artificial  respiration,  the  air  should  hiss  in 
and  out  and  this  is  the  test  of  the  efficiency  of  the  artificial  respiratory 


TRACIIl'OTOMY.  605 

movements.  Of  course,  if  ilic  wduml  is  [iroperly  spread  with  the  Trousseau 
forceps  or  a  hemostat  or  the  cannula  is  inserted  there  is  no  hissing  sound 
but  the  air  passes  in  and  out  and  there  are  always  thin-blown  bubbles  of 
blood  and  secretion  to  indicate  that  the  artificial  respiration  is  forcing 
the  air  to  move  in  and  out.  The  use  of  oxygen  and  amyl  nitrite  at  this 
stage  has  been  referred  to  above. 

If  the  operation  has  to  be  done  in  the  dark  as  has  happened  twice 
in  the  author's  experience,  the  left  index  finger  feels  the  thyroid  notch 


\ 


Fig.  449.^Siil)stitiitc  sccuiul  stuKf  of  the  author's  two-stage  finger-guided 
emergency  tracheotomy.  This  plan  for  the  second  stage  is  easier  for  many  oper- 
ators, than  that  shown  in  Fig.  448.  In  practice  the  whole  wound  is  a  pool  of 
blood,  in  which  the  trachea  cannot  be  seen.  The  trachea  is  here  shown  free  of 
blood  to  illustrate  how  it  is  found  by  palpation  with  the  left  index,  which  also 
serves  as  a  guide  for  the  knife  that  is  slid  down  along  the  index  in  making  the 
tracheal  incision.     The  autlior  prcfi-r^  t)ie  second-stajje  position  sluuvn  in  Fig.  448 


in  the  first  stage  (Fig.  I  17).  The  incision  is  guided  along  the  promin- 
ent central  safety  ridge  by  the  fourth  and  fifth  luigcrs  of  the  r'n/ltt  hand 
of  which  the  ihunib  ami  tlrsi  \\\n  \]n'^ur<.  arc  hdlilini;  the  knife.  The  sec- 
ond stage  is  the  same  as  if  there  were  light. 

The  author  has  found  in  teaching  his  method  of  emergency  tracheo- 
tomy to  others,  that  some  ])ersons  arc  un;iblc  to  use  the  index  freelv  and 
independently  for  i)alpation  while  fixing  the  trachea  with  the  thumb  and 
the  median  finger.  I"or  them  the  second  stage  is  easier  executed  as 
shown  in  Fig.  440. 


()06  TRACHEOTOMV. 

RL'LKS  I'OR  EilERGICNCY   TRACHEOTOMY. 

1.  A  Stabbing  operation  is  to  be  avoided. 

2.  Two  incisions  are  better  than  one. 

3.  Press  back  the  neck  each  side  of  tlie  trachea  with  the  thumb  and 
middle  finger  of  the  left  liand  to  throw  the  median  safety  ridge  into  prom- 
inence. 

4.  AJake  a  long  deep  incision  from  the  th\roi(l  notch  almost  to  the 
suprasternal  notch.  Working  down  in  a  small  deep  wound  is  diflicult. 
This  first  incision  should  lay  bare  the  thyroid  and  cricoid  cartilages  and 
a  few  upper  rings  of  the  trachea,  but"  you  cannot  see  them  for  blood. 

5.  Feel  for  the  corrugated,  wash-board-like  trachea  in  the  wound. 
().     Incise  the  trachea  while  feeling  it  with  the  index. 

T.  Make  the  incision  below  the  cricoid — preferably  below  the  first 
ring  of  the  trachea. 

S.  Don't  expect  a  hiss  of  air  if  the  patient  is  not  breathing.  Slip 
in  a  cannula  and  start  artificial  respiration. 

9.  Artificial  respiration  should  force  air  in  and  out  of  cannula  if 
everything  is  right. 

10.  Amyl  nitrite  blown  in  with  oxygen,  is  the  best  restorative  in 
respiratory  arrest.  Both  may  be  drawn  in  by  artificial  respiration  by 
the  method  described  in  a  preceding  paragraph  headed  "Position  of  as- 
sistants for  tracheotomy  and  artificial  respiration." 

Al'TER-CARE   l>I"   TR.VCHEoTOMIZKD   CASE. 

A  laxative,  as  after  any  other  operation,  is  usually  advisable.  In 
regard  to  diet,  if  there  be  no  contraindication  pertaining  to  the  condition 
for  which  the  tracheotomy  has  been  done,  and  the  temperature  be  nor- 
mal, there  is  no  reason  why  the  tracheotomized  patient  should  not  have 
a  light  tray.  Occasionally  a  patient  is  encountered  who  will  have  some 
difticulty  with  food  finding  its  way  into  the  larynx,  but  this  is  exceedingly 
unusual.  Ordinarily,  tracheotomized  patients  are  able  to  swallow  after 
the  operation  just  as  well  as  before.  Cleanliness  of  the  mouth  must  be 
insured  by  brushing  the  teeth  after  taking  food,  and  by  the  frequent  rins- 
ing of  the  mouth  with  alcohol  1  part  to  ■")  of  water.  .\s  the  cough  reflex 
is  the  watch  dog  of  the  lungs,  antibechics,  especially  bromides  and  all  the 
opium  derivatives,  should  be  particularly  forbidden.  The  old-fashioned 
croup  tent  is  of  no  value,  and  possibly  is  injurious  to  tracheotomized 
patients.  It  certainly  deprives  them  of  the  co])ious  ventilation  which  is 
necessary.  There  is,  however,  in  our  clinic,  abundant  evidence  proving 
that  vaporization  of  compound  tincture  of  benzoin  from  hot  water  in  the 
room  is  beneficial.     Plenty  of  fresh  air  is  absolutely  essential.     .-\t  least 


TKACIllluTOMV.  G07 

one  window  shoiiid  never  Ijc  closed  in  any  weather,  exce])t  during  bath- 
ing or  sponging. 

A  good  nurse  experienced  in  tracheal  work  is  vital.  In  the  author's 
work  the  special  tracheal  nurses  have  saved  hundreds  of  lives  that  would 
have  l)een  lost  under  any  good  capable  nurse  with  general  training,  but 
without  special  training  in  tracheal  work.  They  know  how  to  sponge 
away  secretion  before  it  is  drawn  in  again.  .\11  these  nurses  know  by 
the  sound  when  the  breathing  is  clear  and  they  are  competent  to  remove 
the  outer  cannula  and  replace  it  with  a  clean  one.  Without  special  train- 
ing and  experience,  the  nurse  or  even  the  interne  should  not  be  i)ermitted 
to  change  the  outer  cannula.  The  inner  cannula  should  be  removed  by 
the  nurse  as  often  as  necessary.  In  certain  cases  of  very  thick  secre- 
tion, the  cannulae  mav  become  gummed  together  and  occluded  so  much 
that  though  air  still  comes  through,  it  is  not  in  sufficient  quantity,  and, 
worst  of  all,  the  secretions  cannot  get  out.  Such  cases  often  require 
the  removal  of  both  the  cannulae,  every  hour,  for  evacuation  of  secre- 
tions that  will  not  come  out  through  the  tube.  In  ordinary  cases,  how- 
ever, the  removal  of  the  outer  cannula  once  daily  is  sufficient.  It  is 
most  astonishing  to  see  the  statement  in  print,  and  to  hear  surgeons  ad- 
vise, the  cleaning  of  the  outer  cannula  at  such  intervals  as  a  week  or 
even  a  month.  D.'iilv  cleansings  of  the  outer  cannula  are  imperative. 
The  nurse  must  be  trained  to  dress  the  wound,  for  the  dressing  must  be 
done  very  fre(|uently,  even  every  half-hour,  if  secretions  are  abundant. 
The  old  surgical  rule  to  disturb  the  wound  by  dressing  as  seldom  as 
possible,  is  one  of  the  causes  of  the  high  mortality  of  tracheotomy  under 
routine  surgical  regime.  Conditions  here  are  entirely  different  from 
anywhere  else  in  the  bodv.  The  air-infected  secretions  and  discharges 
must  be  absorbed  and  remo\ed  by  very  frequent  dressings,  dauze, 
wrung  out  of  mercuric  chloride.   1  :  10,000,  is  used  in  three  ])ieces. 

a.  A  large,  thick,  folded  ]>iece  to  pack  ardund  ilie  cannula.  (  Xot  a 
narrow^  strip.) 

b.  .\  bib  |iiece  on  the  surface  surrounding  the  stem  of  the  can- 
nula under  the  ta|ie-holders. 

c.  .\  filter  piece  to  lay  over  the  entire  front  of  the  neck. 

This  latter  ])iece  should  be  changed  as  often  as  soiled,  even  if  e\ery 
ten  minutes.  P.oth  the  filter  and  bib  pieces  should  be  fastened  by  small 
safety  pins,  at  the  side  of  the  neck,  to  the  tapes  which  hold  llic  cannula. 
Thus  no  bandage  is  needed.  Duplicate  cannulae  for  each  case  facilitate 
dressings  and  permit  of  repairs.  If  only  one  caimula  is  available,  the 
cleaning  is  apt  to  he  done  hastily  resulting  in  imperfect  cleansing  or  in 
damage  to  the  cannula.  Dinged  edges  are  certain  to  cause  erosions  and 
cicatrices.     Tracheotomic  cannulae  when  worn  lor  a  long  lime,  no  mat- 


f;os 


TRACHEOTOMY. 


ter  of  how  good  construction,  nor  how  carefully  cleaned,  become  dam- 
aged and  should  be  carefully  watched  for  beginning  breakage.  The  most 
common  accident  is  the  breaking  off  of  the  tube  from  the  tape  holder 
with  resultant  escape  of  the  tube  down  the  trachea.  Before  the  days  of 
bronchoscopy  this  was  a  very  grave  accident.  Hunt  (Bib.  211)  re- 
ports a  very  interesting  bronchoscopic  removal  of  a  very  large  cannular 
tube.     Coolidge  removed  one  in  ISiili,  one  of  the  earliest  bronchoscopies. 


Fig.  450. — Schematic  illustration  of  Dr.  Ellen  J.  Patterson's  method  ot  attach- 
ing the  tapes  to  tracheotomic  cannulae.  Near  the  end,  A,  a  slit  is  cut  in  the  tape 
with  scissors,  the  tape  heing  folded  for  cutting.  The  end.  A,  is  then  passed 
through  the  slot  in  the  tape  plate  from  the  under  side  as  shown  at  D.  The  end, 
B,  is  then  pulled  through  the  slit  in  the  tape,  and  drawn  taut  as  shown  at  C.  The 
tape  must  be  of  pood  strong  linen  and  must  not  be  less  than  19  mm.  (three- 
fourths  inch)    wide. 


Man_\-  parts  of  the  cannulae  have  been  removed  since,  and  while  almost 
all  have  Ijeen  successful,  yet  the  patient  may  asphyxiate,  and  every  care 
should  ])e  taken  to  see  that  the  cannulae  are  in  perfect  condition.  Can- 
nulae. especially  inner  ones,  re(|uire  careful  cleaning.  It  is  (|uite  common 
to  find  nurses,  unless  specially  taught,  failing  to  get  otu  all  the  inucus 
from  the  central  part  of  the  tube.  This  is  boiled  in  place,  and  hence 
the  canntila  gets  obstructed  soon  after  replacing.  The  pipe  cleaners  sold 
by  tobacconists  are  excellent  for  cleaning  tubes,  two  or  more  being  used 
at  once,  in  a  bundle. 


TRACHEOTOMY.  609 

The  cannula  may  be  obstructed  by  exuberant  granulations.  These 
should  be  removed  with  forceps,  which  method  is  preferal)le  to  caustics 
in  our  experience.  Tracheal  papillomata  may  obstruct  the  cannula  and 
may  appear  in  great  abundance  in  the  trachea  after  they  are  removed 
from  the  larynx.  They  should  be  searched  for  with  a  small  broncho- 
scope and  removed  with  forceps  and  pure  alcohol  may  then  be  applied 
carefully  to  the  points  from  which  they  spring,  being  especially  careful 
not  to  allow  any  to  get  down  into  the  trachea.  Obstruction  of  the  can- 
nula by  membrane  in  diphtheritic  cases  is  not  at  all  uncommon,  and  re- 
quires prompt  action  on  the  part  of  the  nurse. 

The  tapes  are  attached  to  the  cannula  before  the  caniuila  is  intro- 
duced. The  manner  of  attaching  the  tapes  to  the  tube,  clearly  illustrated 
in  Fig.  4.'J0,  has  been  in  constant  use  in  our  clinic  for  many  years  with 
great  satisfaction.  .\  jiilot  should  always  be  used  to  prevent  trauma,  and 
for  the  first  week  the  Trousseau  dilator  must  be  used  to  spread  the 
tracheal  incision  to  avoid  trauma  to  the  cartilages.  The  little  bent  wire 
loops  that  are  usually  attached  to  the  inner  cannula,  are  very  much  in 
the  way  in  sponging  away  the  secretions,  and  considerable  practice  on 
the  part  of  the  nurse  is  necessary  in  order  quickly  to  wipe  clean  the 
coughed  out  secretions  from  between  these  loops  before  the  secretions 
are  drawn  in  again.  The  wire  loops  may  be  done  away  with  and  the 
finger  nail  used  to  withdraw  the  inner  cannula.  But  if  this  is  done, 
there  may  be  serious  delay  in  remo\ing  the  inner  cannula  in  case  it 
becomes  obstructed,  and  as  this  might  be  such  a  serious  matter,  the 
author  has  preferred  to  leave  on  the  wire  loops  and  to  train  the  nurses 
to  \\i|n.'  between  them.  There  should  be  no  Ijreathing  sound  andilile 
with  a  properly  fitted  cannula.  The  classical  "stridor  serraticus"  which 
used  to  be  considered  as  properly  pertaining  to  the  cannulated  patient 
is  noticeable  by  its  absence  with  a  proper  cannula,  exce])t,  of  course, 
when  the  cannula  is  obstructed  with  secretion  or  when  the  patient 
coughs.  .-X  sterile  "tracheotomy  tray"  should  \k-  in  the  room  of  every 
tracheotomized  i)atient. 

.'\  tracheotomy  tray  should  contain : 

Tracheal  canimla.  duiilicate  of  one  ])atient  wears. 

Trousseau  dilator. 

Dressing  forceps. 

Scissors. 

Sterile  vaseline. 

Tape. 

Gauze  sponges. 

Gauze   sr|uares. 

Sol.  mercin-ic  biclilnride -1  -  lo  iioO. 


610  TRACHKOTOMY. 

In  the  after  care  of  tracheotomized  cases,  it  is  necessary  to  remem- 
ber that  edema  of  the  hnigs,  pneumonia,  broncho-pneumonia  and  fatal 
bronchitis  are  the  rarest  of  complications  following  tracheotomy.  Many 
patients  die  from  unrecognized  purely  mechanical  conditions  and  very 
few  from  the  just-mentioned  diseases.  When  a  patient  is  not  doing 
well,  the  trachea  should  be  examined.  It  is  necessary  to  remember  that 
dvspnea  or  obstructed  breathing  or  simple  "sinking  of  the  patient"  ap- 
parently of  exhaustion  and  without  dyspnea  may  be  due  ti) 

(a)  Obstruction  of  the  cannula  by  dried,  cooked,  thick  or  even 
thin  secretion. 

(b)  Obstruction  of  the  trachea  itself  by  the  same  substances  below 
the  caniuila. 

(c)  Obstruction  of  the  trachea  by  compression. 

(d)  Cannula  not  reaching  into  the  trachea. 

,  Decannulafion.  The  cannula  should  not  be  abandoned  until  the 
patient  can  sleep  quietly  with  the  outer  cannula  in  place,  the  inner 
cannula  being  removed  and  a  tight  fitting  cork  placed  in  the  outer  orifice 
of  the  outer  cannula.  If  the  patient  cannot  do  this,  the  larynx  is  stenosed 
and  special  work  will  be  needed  to  decannulate  the  patient  as  will  be 
explained  in  a  future  chapter.  When  the  cannula  is  no  longer  needed 
the  wound  must  be  packed  so  as  to  heal  from  the  bottom  outward. 
There  will  never  be  cartilaginous  union,  but  fibrous  union  of  the  divided 
edges  of  the  tracheal  incision  must  be  complete  before  the  outer  tissues 
are  allowed  to  close.  Plealing  cartilage  is  prone  to  be  associated  with 
exuberant  granulations  aufi  these  may  occlude  the  trachea  and  require 
a  new  tracheotomy  for  dyspnea.  A  number  of  such  cases  have  been 
sent  to  the  author,  who  located  the  trouble  bronchoscopicall\'.  (  See  Fig. 
12,  Plate  II,  in  the  earlier  volume.  Bib.  'H>i).)  In  order  to  keep  the 
wound  open,  it  is  necessary  to  pack  it  firmly,  not  with  a  strip  of  gauze 
an  end  of  which  might  get  into  the  trachea,  but  with  a  small  firm  roll  of 
gauze  wedged  into  the  depression  corresponding  to  the  wound,  which 
latter  is  first  overlaid  with  a  large  piece  of  gauze  that  covers  the  entire 
front  of  the  neck,  including  the  wound,  as  will  be  illustrated  in  connec- 
tion with  thyrotomy. 

Cor.ipUcaiions.  Erysipelas,  diphtheritic  and  severe  pyogenic  infec- 
tions of  the  wound  ought  to  he  exceedingly  rare  if  a  very  careful  aseptic 
technic  is  carried  out.  Even  streptococcic  and  pneumococcic  infections 
from  the  air  passages  in  previously  purulent  cases,  are  exceedingly  in- 
frecjuent  if  the  author's  method  of  frequent  dressings,  (every  one  to 
three  hours),  be  followed,  especially  when  the  dressings  are  wrung  out 
of  one  to  ten  thousand  bichloride  solution.  Tracheal  ulcerations  from 
pressure  of  the  cannula  are  exceedingly  rare  if  the  cannula  fit  properly. 


TRACHEOTOMY.  611 

.^uch  ulcerations  may  be  followed  by  cicatricial  contractions  resulting  in 
stenosis.  The  most  serious  of  all  complications  is  necrosis  of  more  or 
less  of  the  cartilaginous  rings,  and  this  is  sure  to  result  in  more  or  less 
stenosis.  This  comjilication  is  best  avoided  by  the  directions  given  for 
preserving  the  perichondrium  and  the  inter-annular  membrane,  and  by 
careful  selection  of  the  caimida  to  fit  the  patient.  ( )pen  air  treatment 
is  one  of  the  best  projihylactic  and  therapeutic  measures  for  all  infective 
com])lications. 

Hemorrhage  after  tracheotom_\-  may  occur  especially  iluring  the 
straining  of  coughing  A  vein  or  artery  may  lose  its  ligature,  but  as  it 
is  exceedingly  rarely  that  vessels  of  any  size  are  cut  through,  it  is  not 
usually  a  serious  matter,  unless  a  great  quantity  of  blood  should  get  down 
into  the  air  passages.  The  best  way  to  arrest  it  is,  of  course,  to  open 
up  the  wound  and  search  for  the  bleeding  points  with  hemostats.  If  the 
vessels  have  retracted  into  the  soft  tissues,  it  may  take  some  little  search, 
but  they  can  always  be  found.  Ordinarily,  subcutaneous  emphysema  fol- 
lowing tracheotomy  is  of  little  conse(|uence  and  soon  disappears.  It  is 
much  more  likely  to  appear  if  the  tracheal  wound  is  sutured,  but  oc- 
casionally hapi)ens,  though  rarely,  with  wounds  packed  open. 


CHAPTER     XXXVIII . 

Chronic  Stenosis  of  the  Larynx  and  Trachea.* 

Chronic  stenosis  almost  invariably  comes  to  the  surgeon  in  the 
form  of  a  tracheotomized  or  intubated  patient  who  cannot  abandon  his 
cannula  or  intubation  tube  because  of  the  larj-ngeal  stenosis.  There- 
fore, it  will  contribute  to  clearness  to  consider  the  subject  from  this 
viewpoint.  The  different  forms  of  laryngeal  stenosis  associated  with 
difficult  decannulation  or  extubation  may  be  classified  into  the  follow- 
ing  types : 

1.  Panic. 

2.  Spasmodic. 

3.  Paralytic. 

4.  Ankylotic    (arytenoid). 

5.  Neoplastic. 

G.     Hyperplastic. 
7.     Cicatricial. 

(a)  Loss  of  cartilage. 

(b)  Loss  of  muscular  tissue. 

(c)  Fibrous. 

Panic.  Breathing  through  the  neck  with  a  properly  placed  tracheo- 
tomic  cannula  is  so  much  easier  than  breathing  through  the  mouth  that, 
once  the  patient  becomes  accustomed  to  tracheotomic  breathing,  for 
quite  a  while  he  does  not  feel  that  he  is  getting  enough  air  through  the 
mouth,  even  though  the  larynx  is  perfectly  patulous.  In  addition  to 
this  there  is  a  "nerve  cell  habit"  arising  from  previous  experience  with 
the  stenosis  that  terrorizes  the  patient,  especially  a  child,  the  moment  he 
feels  the  slightest  dyspnea.  In  children  crying  tends  to  increase  stenosis 
(by  disturbance  of  resjjiratory  rh\thm  and  by  venous  engorgement), 
and  fright  is  very  apt  to  do  so  in  either  adults  or  children.  Glottic 
spasm   may   or   may   not    contribute.      .Ml    these   things   taken   together 

♦lievised,   with  additions,   from   thie  autlior's    paper    read    l>efore    the    American 
Laryngologrical    Association,    1913.      (Bib.  26:i.     Interesting   discussion.) 


CHRONIC   STENOSIS   OF    TIIIC   LARYNX    AND   TRACIIKA.  613 

may  be  called  "panic"'  and  constitute  cjuite  a  formidable  obstacle  to 
decannulation  even  where  there  is  no  real  stenosis  of  the  larynx. 

Spasm.  Spasmodic  stenosis  may  be  associated  with  ])anic,  or  may 
be  excited  by  subglottic  inflammation.  It  is  usually  overcome  by  the 
same  means  as  those  suggested  for  ])anic,  together  with  the  treatment  of 
the  inflammatory  condition  that  may  be  present.  Doubtless  one  of  the 
chief  causes  of  adductor  spasm  is  the  prolonged  wearing  of  an  intubation 
tube,  especially  a  large  one,  which  ])revents  activity  of  the  adductors,  and 
of  the  abductors ;  because  the  action  of  these  two  sets  of  muscles  is  re- 
ciprocal, and  the  normal  balance  is,  of  course,  interfered  with  by  the 
presence  of  an  intubation  tube  for  a  long  period.  Three  methods  of  treat- 
ment may  be  used  in  these  cases  to  get  the  patient  permanently  extubated. 
1.  Replacing  the  intubation  tube  with  a  special  one,  which  has  a  very 
narrow  neck  with  a  long  anteroposterior  lumen  in  order  to  allow  free 
glottic  action  for  a  time,  until  muscle  balance  is  restored.  2.  In  a  few 
cases  of  not  very  severe  type  it  is  possible  to  get  them  well  by  a  patient 
extubation  with  replacement  as  soon  as  the  child  begins  to  get  blue.  This 
requires  a  facile  intubator  who  has  plenty  of  confidence  in  his  ability  to 
slip  in  the  intubation  tube  promptly  and  without  trauma.  This  method 
will  not  succeed  in  a  violently  spasmodic  type,  where  the  symptoms  are 
so  urgent  and  severe  that  the  tube  can  be  left  out  for  only  a  few  seconds. 
But  in  the  less  severe  ty])e  of  cases  it  is  (juite  often  successful.  3. 
Tracheotomy  for  extubation  is  the  C|uickest  method  of  cure  in  purely 
spasmodic  cases  without  organic  stenosis.  The  wearing  of  a  tracheotomic 
cannula  for  a  week  or  two  will  permit  the  restoration  of  muscle  balance, 
and  by  corking  the  cannula  with  a  slotted  cork,  as  elsewhere  herein  men- 
tioned, the  child  can  be  gradually  weaned  away  from  the  cannula,  and 
thus  ]5ermanently  extubated  and  decannulated. 

Paralysis,  liilateral  laryngeal  paralysis  causes  a  severe  stenosis  of 
the  larynx.  ])ro\ided  the  paralysis  is  not  cadaveric.  In  cadaveric  paralysis 
there  is  usually  sufficient  breathing  space,  and  this  has  led  to  operative 
nerve  division  to  relieve  stenosis.  The  author  agrees  with  Charles  H. 
Knight  that  nerve  <li\isi()n  has  been  a  faihu'e,  but  llie  author  has  thought 
that  nerve  excision  might  yield  better  results.  In  ibe  one  case  in  which 
the  author  tried  nerve  excision,  it  was  a  failure  In  decannulation  in 
paralytic  larynge.'il  stenosis  three  methods  of  trealnienl  may  be  fi}lloued. 
Cordectemy  has  yielded  good  results  in  rare  instances,  the  cords  being 
excised  either  by  thyrotomy  or  endolaryngeally.  The  author  had  one  suc- 
cess after  evisceration  of  tin'  larynx  endoscopically  by  the  direct  method. 
The  results  of  tbyrotoniic  evisceration  (Fig.  I'll  )  are  absolutely  ideal  in 
cases  where  there  are  no  lesions  other  than  the  bilateral  paralysis. 
Formerly,  when  it  was  thought  that  excision  of  the  cords  meant  perma- 


614  CHRONIC    STF.XOSIS    OF    TIIK    LARVXX    AND   TRACHEA. 

nent  loss  of  voice  one  might  hesitate  to  recommend  evisceration.  In  two 
cases  operated  upon  by  the  author  a  fairly  loud,  though  very  rough 
phonation,  mostly  in  a  monotone,  was  obtained  by  both  the  patients.  It 
was  a  good  useful  \oice.  in  both  instances,  though,  of  course,  it  did  not 
have  the  flexibiltiy  that  we  see  after  thyrotomy  for  conditions  in  which 
there  is  unimpaired  mobility  of  the  arytenoid  joints.  In  both  of  these 
cases,  however,  the  author  did  a  careful  dissection,  taking  out  all  the  soft 
tissues  and  not  simply  the  cords  alone.  The  technic  was  the  same  as  for 
thyrotomy  ( q.  v.)  except  that  the  perichondrium  was  not  removed,  and 
the  dissection  was  done  on  both  sides  instead  of  onlv  one.  l^oth  patients 
were  permanently  decannulated.  Great  care  is  necessary  to  make  sure 
that  all  of  the  sub-glottic  tissue  is  dissected  out.  Of  course  the  operation 
is  only  to  be  recommended  when  the  paralysis  is  unassociated  with  essen- 
tiall\-  fatal  conditions,  such  as  aneurj'sm  and  malignant  mediastinal 
tumors.     George  L.  Richards  reports  a  case  in  which  spontaneous  recov- 


1.1 

Fig.  451. — Schematic  representation  of  evisceration  of  the  larynx  for  chronic 
paralytic  stenosis.  The  dotted  line  represents  the  line  of  dissection,  endoscopic  or 
thyrotomic. 

ery  from  a  laryngeal  paralysis  occurred,  but  that  was  in  a  chilil  and  was 
for  a  short  time  only.  As  a  rule,  it  may  be  said  that  when  bilateral  paraly- 
sis remains  twelve  months  it  will  never  be  followed  by  recovery,  because 
of  muscle  atrophy  or  joint  stiffening.  Therefore,  the  operation  is  justifi- 
alile,  if  the  patient  wishes  to  be  decannulated  and  considers  some  impair- 
ment of  voice  more  than  outbalanced  by  the  getting  rid  <if  the  cannula  and 
by  being  made  absolutely  safe  from  asphyxia.  It  is  rather  appalling  to 
note  the  number  of  patients  with  Ijilateral  laryngeal  paralysis  that  have 
died  as  a  result  of  accident  to  the  intubation  tube  or  cannula.  In  bilateral 
recurrent  j)aralysis  of  recent  occurrence  it  may  be  worth  while  to  attempt 
suturing  the  recurrent  to  the  pneumogastric,  provided  the  paralysis  is  re- 
cent, even  if  it  is  not  peripheral.  Monolateral  paralysis  does  not  usually 
cause  sufficient  dyspnea  to  call  for  a  tracheotomy,  but  it  is  worthy  of  note 
that  excision  of  a  scar  and  suture  of  the  recurrent  laryngeal  after  injtiry 
has  been  successful  in  restoring  motion  to  one  cord  (J.  Shelton  Horsley 
and  Clifton  IM.  ]\liller). 


CHRONIC    STKNOSIS    01'    THI':   I,AK^■^■^■    AND   TRACHEA.  CIS 

Anhylosis.  Ililatcral  ankylolic  coiulitiuns  of  the  cricoarytenoid  joints 
may  prevent  decannulation  until  the  laryngeal  stenosis  is  relieved.  In  one 
case  of  this  kind,  thyrotomic  exisceration  of  the  larynx,  as  mentioned 
above  for  paralysis,  completely  cured  the  stenosis  in  a  man  forty  years 
of  age.  (Fig.  4--)l.)  ( )f  course,  evisceration  is  not  to  be  advised,  except 
in  such  cases  as  have  remained  rigid  for  a  period  of  twelve  months  or 
more,  and  it  is  not  meant  to  include  the  fixation  that  is  associated  with 
malignant,  tuberculous  or  k-utic  intillrations.  Endoscopic  evisceration 
(Fig.  I."i2  )  is  ]ireferable  to  thyrotomic  evisceration.  (For  tcchnic  of  endo- 
scopic evisceration,  see  Chapter  \'TI.) 

Neoplasms.  l.)ecannul;uion  in  neoplastic  cases  will,  of  course,  de- 
pend, so  far  as  stenosis  is  concerned,  upon  the  nature  of  the  growth  and 
its  curability.  In  malignant  conditions  after  tliyrotomy,  stenosis  prac- 
tically never  occurs.  After  hemilaryngectomy.  stenosis  may  follow  from 
a  flaccid  ccmdition  of  the  side  wall  of  the  larynx,  or  there  may  be  a  cica- 
tricial contraction  diminishing  the  stenosis.  .-\s  a  rule,  in  these  cases,  the 
author  believes  the  best  treatment  is  continuous  dilatation  from  the  pro- 
longed wearing  of  a  large  intubation  tube,  though  it  is  better  to  defer 
inlubational  dilatation  until  quite  certain  that  the  malignancy  is  not  going 
to  recur;  becavise  if  the  malignancy  recur  re-operation  for  malignancy  can 
be  so  planned  as  to  take  care  of  the  stenosis,  by  evisceration  of  the  normal 
half  of  the  larynx.  In  cases  of  stenosis  associated  with  benign  tumors 
other  than  iiapillomala.  decannulation  rarely  presents  difificulties.  The 
removal  of  the  tumor  usually  restores  the  laryngeal  lumen. 

Papilloiiiata.  Tapillomata  ])resent  c|uite  a  ditTereut  ijroblem,  inas- 
much as  the  growths  persistently  recur,  though,  of  course,  unlike  malig- 
nancy, they  do  not  infiltrate.  Their  remo\al  usually  restores  the  lumen 
and  the  patient  may  lie  thus  readily  decaiuuilated  :  but  recurrence  must 
be  carefully  watched  for  and  removed  before  the  stenotic  stage  is  reached. 
As  a  rule,  it  is  better  to  wait  for  ;il  least  six  months  after  discontinuance 
of  recurrence  before  begimiing  decannulation  as  hereafter  described.  If 
|)apillomata  have  been  carefully  removed,  and  no  injury  has  been  done  to 
the  motor  area  of  the  larynx,  there  will  be  no  cicatricial  stenosis.  I'n- 
fortunately,  (|uite  a  number  of  cases  are  seen  in  which  direct  or  indirect 
operations  ha\e  removed  masses  of  normal  tissue,  which  has  been  fol- 
lowed by  severe  cicatricial  stenosis,  in  some  instances,  the  motor  area 
has  been  damaged  .so  as  to  lead  to  ankylotic  stenosis. 

Compression  stenoses  of  the  trachco.  Peritracheal  neoplasms  oc- 
casionally cause  compression  sli-uosis  as  do  also  hyperlro|)hy  i)f  the  lh_\- 
mus  and  thyroid  glands.  Decannulation  in  a  thymic  compression  ((|.  \'. ) 
case  is  \ery  readily  accomplished  by  either  tii\niopexy  or  a  subtotal  thy- 
mcct(]niy,     .\  struma  can  be  de.-ill  with  b\-  the  usual  well  known  methods. 


616  CHROXIC    STENOSIS    OF    THE    I.ARYNX    AND   TRACHEA. 

Hyl'er plastic  and  cicatricial  chronic  stenoses  preventing  decannula- 
tion  may  be  classified  etiologically  as  follows : 

1.  Tuberculosis. 

2.  Lues. 

3.  Scleroma. 

4.  Acute  infectious  diseases. 

(a)  Diphtheria. 

(b)  Typhoid  Fever. 

(c)  Scarletina. 

(d)  Measles. 

(e)  Whooping  Cough. 

5.  Decubitus. 

(a)  Cannular. 

(b)  Tubal. 

6.  Trauma. 

(a)  Tracheotomic. 

(b)  Intubational. 

(c)  Operative. 

(d)  Suicidal  and  homicidal. 

(e)  Accidental     (by     foreign     bodies,     external 

\iolence,  bullets,  etc.) 

Most  of  the  organic  conditions,  outside  of  the  paralytic  and  neoplas- 
tic forms,  are  almost  all  the  result  of  inflammation,  often  with  ulceration 
and  the  secondary  tissue  changes.  In  the  infective  granulomata,  such  as 
lues  and  tuberculosis,  and  in  the  acute  infectious  diseases,  it  is  practically 
always  the  mixed  infections  from  oral  sepsis  running  riot  that  do  the 
harm.  The  chief  exception  to  this  is  diphtheria,  which  in  many  cases  is 
distinctly  a  necrotic  process,  wherein  the  replacement  of  the  lost  tissue  by 
cicatricial  tissue  causes  the  stenosis  either  by  cicatricial  contraction  or  by 
the  bulk  of  the  newly  formed  inflammatory  infiltrate  or  of  pus  collec- 
tions. Typhoid  fever  ((].  v.)  is  also  associated  with  necrotic  processes 
in  some  instances. 

Tuberculosis.  In  the  rare  cases  in  which  laryngeal  tuberculosis  of 
such  severe  type  as  to  demand  tracheotomy  is  cured,  decannulation  usual- 
ly presents  little  difficulty  after  the  infiltrations  are  reduced.  Should 
cicatricial  stenosis  from  ulceration  persist,  it  is,  of  course,  to  be  treated 
in  the  same  way  as  cicatrices  in  other  cases,  by  laryngostomy.  The  author 
has  seen  but  a  single  case  of  this  kind.  In  the  non-cicatricial  forms, 
which  arc  relatively  common,  laryngostomy  is  not  necessary,  and  direct 
ajjplication  of  the  cautery  will  give  such  a  degree  of  reduction  of  infiltra- 
tion as  to  give  an  ample  lumen. 


CHRONIC   STENOSIS   01"    TIIK   LAKVNX    AND   TRACHKA.  G17 

L"cs.  Swain  reports  a  case  of  luetic  immobility  of  both  cords  in 
which  the  intermittent  wearing  of  an  intubation  tube  gained  suf¥icient 
lumen  in  the  larj-nx  for  respiration  until  general  medication  cured  the 
patient.  I'nder  the  careful  watchfulness  of  Dr.  Sw-ain,  such  a  procedure 
was  safe,  but  as  a  rule  patients  are  far  safer  with  a  tracheotomy.  Luetic 
cicatrices  are  proverbially  prone  to  return,  and  are  particularly  vicious  in 
contraction.  Prolonged  stretching  with  oversized  intubation  tubes  follow- 
ing either  incision  with  the  galvano-cautery  or  e.xcision  with  cutting  for- 
ceps is  sometimes  successful.  biU  usually  laryngostomy  is  required.  In 
those  old  cases  of  chronic  luetic  fibrosis,  which  are,  in  a  sense,  paraluetic 
conditions  little,  if  at  all.  amenable  to  the  older  methods  of  medication, 
salvarsan  has  accomplished  wonders.  It  has  even  been  claimed  that 
cicatrices  of  luetic  origin  have  been  benefited.  It  would  seem,  however, 
that  in  such  cases  there  must  have  been  an  underlying  fibrosis  of  the  na- 
ture of  a  luetic  lesion,  and  not  purely  and  simply  a  cicatricial  condition 
following  such  a  lesion.  Scar  tissue  is  scar  tissue,  regardless  of  what 
prf)(luceil  it,  and  we  must  rely  upon  laryngostomy  for  the  cure  of  most 
of  these  scarred  conditions. 

Scleroma.  Dr.  Emil  Mayer  recommends  the  use  of  radiotherapy  in 
the  treatment  of  scleroma.  If  the  stenosis  is  severe,  doubtless  it  would 
be  well  to  open  the  larynx  externally  and  keep  it  open  as  in  laryngostomy, 
so  that  the  applications  of  the  ray  could  be  direct  to  the  scleromatous 
tissue.  Previously  the  results  of  treatment  of  scleroma  were  unsatis- 
factory, and  those  unamenable  to  ray  treatment  probably  constitute  the 
onlv  cases  of  chronic  laryngeal  stenosis  in  which  decannulation  is  impos- 
sible. 

Diphtheria.  Diphtheritic  cases  may  be  of  the  panic,  spasmodic  or, 
rarely,  the  paralytic  types ;  but  more  often  the  stenosis  is  of  either  the 
hypertrophic  or  cicatricial  forms.  After  intubation,  especially  if  i)ro- 
longed,  there  may  be  a  hypertrophic  condition,  which  is  manifest  in  two 
ways:  1.  An  edematous  condition  of  the  up])er  orifice  of  the  larynx, 
usually  worse  anteriorly  around  the  base  of  the  epiglottis  but  also  in 
some  instances  extending  backward  over  the  glossoepiglottic  fold  and  the 
ventricular  band,  either  or  both.  (Fig.  11.  Plate  I.)  To  this  form,  the 
author  has  giver,  the  name  supraglottic  hypertro])hy.  It  resembles  some- 
what the  ordinary  acute  laryngeal  edema,  exce])t  that  it  is  firmer,  seems 
to  be  chiefly  anteriorly,  is  more  sharply  limited  than  the  latter  lesion 
usually  is,  and  it  has  somewhat  of  a  tendency  to  overhang  and  occlude 
inspiration  more  than  ex[)iralion.  The  supraglottic  hypertrophy  the 
author  has  found,  in  some  instances,  to  be  due  to  the  wearing  of  an 
intubation  tube  which  has  a  sharj)  angle  at  its  upper  anterior  edge.  In 
one  instance,  the  IuIjc  was  smootin  and  rounded  in  this  position,  but  was 


018  CHKOXIC    STENOSIS    ()!■    THIC   LARYNX    AND   TRACHEA. 

entirelv  too  thick  in  the  neck  for  the  age  of  the  child.  Where  these  or 
any  other  defects  in  the  tulie  are  suspected  of  being  responsil)le  for  the 
trouble,  it  is  wise  to  change  ilic  tul)e  for  one  of  correct  model  and  size 
and  await  results  before  attempting  any  more  radical  treatment,  though 
local  applications  of  the  galvano-cautery  can  be  made  while  testing  out 
the  effect  of  a  correct  tube.  Excessive  polypoid  supraglottic  hypertrophy 
should  be  excised.  (Fig.  11.  Plate  I.)  The  infraglottic  type  is  usually 
bilateral.  (Fig.  87.)  The  masses  encroach  upon  the  lumen  from  each 
side  like  hypertrophic  turbinals.  Patients  with  either  the  supraglottic  or 
infraglottic  forms,  if  intubated,  should  be  tracheotomized  and  the  in- 
tubation tube  thus  dispensed  with.  They  arc  very  much  safer  with  a 
tracheotomic  cannula  in  place  than  intubated.  In  the  infraglottic  type  of 
hypertroph}-,  the  most  wonderful  results  have  followed  the  author's 
method  of  direct  applications  of  the  galvano-cautery  (  q.  v.)  With  care 
there  is  no  need  of  injuring  any  of  the  muscles  or  either  of  the  crico- 
arytenoid joints.  The  author  and  Dr.  fallen  J.  Patterson  have  never  yet 
failed  to  cure  a  subglottic  hypertrophic  post-diphtheritic  stenosis  by  the 
galvanocauterant  treatment. 

In  the  cicatricial  type  of  post-diphtheritic  stenosis  the  tibrous  tissue 
may  take  many  forms.  In  some  cases  there  is  a  band  running  across  the 
larynx  from  one  side  to  the  other,  it  may  be  between  the  two  ventri- 
cular liands,  between  the  two  cords,  or  from  one  band  to  the  opposite 
cord,  or  to  the  same  cord  of  the  same  side.  Occasionally  tlie  cicatrix  is 
in  the  form  of  a  funnel  with  a  minute  opening  at  the  bottom  of  the  fun- 
nel. (Fig.  1,  Plate  1.)  In  some  instances  there  is  a  web  anteriorly  (Fig. 
4,  Plate  I),  which  very  much  diminishes  the  air  space  and  may  interfere 
with  phonation  or  may  not,  depending  on  the  degree  of  approximation 
possible.  In  two  instances  the  author  has  seen  a  cicatricial  mass  between 
the  arytenoids  posteriorly  with  ankylosis  of  both  joints,  leaving  only  a 
very  small  opening  close  to  the  anterior  commissure.  This  is  unusual. 
More  frequently  the  opening  is  somewhere  in  the  posterior  two-thirds. 
The  management  of  the  panic  and  spasmodic  types  of  post-diphtheritic 
stenosis  has  been  previously  herein  considered.  The  cicatricial  forms 
require  dilatator}-  intuliation  or  laryngostomv  or  both.     (q.  v.) 

Typhoid  fever.  About  ten  years  ago,  when  typhoid  fever  was  very 
prevalent  in  Pittsburgh,  the  author  made  an  investigation  of  the  laryngeal 
complications  (Am.  Journal  Med.  Sciences,  Nov.  190."))  with  the  aid  of 
Dr.  Ralph  Duffy  and  Dr.  Joseph  H.  Barach.  It  was  found  that  the  ulcer- 
ative lesions  in  the  larynx  were  practically  always  the  result  of  a  mixed 
infection,  and  in  some  instances  they  were  due  to  thrombosis  of  a  small 
vessel  with  subsequent  necrosis.  \\  hen  the  ulcerative  processes  reached 
the  perichondrium  cicatricial  stenosis  was  almost  certain  to   follow,  and 


CTIKONIC   STENOSIS    01"    TTIK   I.ARVNX    AND   TRACHEA. 


Gill 


ijractically  all  ot"  the  cases  with  perichmulritis  resulted  in  necrosis  and 
reeiuired  tracheotomy  for  acute  edematous  stenosis.  The  decannulation 
of  these  cases  .vas  chiefly  by  prolonged  intuljation,  with  siiecial  intuba- 
tion tubes,  the  author's  T-shaped  cannula,  and  in  some  instances,  laryn- 
gostoniy.  The  detailed  results  have  been  previously  reported.  (  I'.ib.  'US 
and  2.-)'J  ).  Ankylotic  and  paralytic  post  tyj)h(jid  stenoses  were  treated 
with  excellent  results  liy  Dr.  Kllen  j.  Patterson  and  the  author,  by  endo- 
scopic evisceration  of  the  larynx.  ((|.  v.)  (See  also  Figs.  8()  and  453.) 
Scarlatina  may  be  followed  by  acute  laryngeal  stenosis,  due  to  in- 
fection with  either  stre])ococcic  or  oth.er  jiyogenic  organisms.  There  may 
be  cellulitus  of  the  neck,  choridritus  and  necrosis,  but  these  are  rare.  In 
any  event,  the  stenosis  following  is  cicatricial  and  is  handled  like  anv 
other  cicatricial  stenoses. 


Fu;,  452. — Post-tyiihoid  .-mkylotic  stenosis.  A,  iiililtraticm  of  aryepii^loltic  folds 
and  arytenoid  region  with  li.xaiion  of  cricoar\  tonoid  articnhitiims.  B,  three 
months  later;  inliltration  disappeared,  arytenoids  immoliilc.  C,  twelve 
months  later;  tissues  shrunken  hut  no  ahduction  possible.  D,  result  of  endoscopic 
evisceration,  six  months  after  decannulation.  Xo  mobility  and  no  tendency  to 
formation  of  an  adventitious  cord  in  the  absence  of  a  motile  arytenoid. 


Trauma.  Occasionally  foreign  bodies,  by  a  prolonged  sojourn  may 
ulcerate  through  from  tlie  esojihagus  into  the  trachea,  causing  cicatricial 
stenosis  as  elsewhere  herein  mentioned.  Trauma,  during  the  ])r<ice(hire 
of  intubation,  is  very  often  charged  with  producing  stenosis,  which  pre- 
vents the  abandonment  of  the  intubation  tube.  In  the  author's  experi- 
ence, this  is  excccdinylv  rare,  the  stenosis  lieing  diU'  In  other  causes  inci- 
dental to  the  disease  for  which  the  intubation  is  done.  Diphtheria  is 
essentially  a  necrotic  ])rocess,  that  with  or  without  intubation  is  apt  to 
lea\e  ■•icatricial  •■.tenosis.  and.  ni  tlie  author's  experience,  stenosis  has  fol- 
lowed tr.''.cheotomy  about  as  fre(|uentiy  as  intubation.  Decubitus  is  fre- 
quently referred  to  as  though  it  were  the  presence  of  the  tube  that  caused 
ulceratidU.  It  is  dcjubtful  if  a  pniperlv  litling  intnb;ition  lube  will  cause 
any  ulceration,  no  matter  how  iung  it  remains  if  it  be  free  from  rough- 
ness or  sharp  edges,  and  is  removed  sul'ticientlv  frei|uentlv  to  be  cleaned. 
A  lube  left  ill  l:io  long  mav  be  crusted  with  concretions  that  will  iiroducc 


620  CHRONIC   STENOSIS   OF    THE   I.ARYNN    AND   TRACHEA. 

ulceration.  Lynah  reports  fatal  trauma  from  intubation  tubes  forced 
into  the  tissues  of  the  neck  by  unskilled  attempts  at  intubation.  Tracheo- 
tomy is  so  commonly  postponed  until  the  very  last  moment  that  it  is  most 
frequently  an  emergency  operation.  Consequently  the  incision  in  the 
trachea  is  often  very  much  misplaced,  running  off  at  an  angle,  or  even 
slicing  the  side  ofif  the  trachea  like  a  slab  from  a  log.  Often  also  dam- 
age is  done  with  dilating  forceps  tearing  through  the  interannular  tissue, 
and  at  times  even  denuding  the  cartilage  of  the  rings.  Then  again,  for 
one  reason  or  another,  various  newly  devised  incisions  with  trap  doors 
and  even  with  excisions  of  cartilage  are  tried  experimentally,  nearly  al- 
ways resulting  m  more  or  less  stenosis  after  cicatricial  contractions  set 
in.  (Fig.  12  and  1(1,  Plate  I,  and  Fig.  443.)  Undoubtedly  in  the  inser- 
tion of  a  trachcotomic  cannula,  especially  if  it  be  done  without  a  pilot, 
it  is  very  easy  to  denude  the  posterior  wall  of  the  trachea,  and  in  time 
an  ulceration  may  follow,  which  may  be  attributed  to  decubitus,  when 
really  it  is  simply  oft-repeated  trauma.  A  properly  fitted  trachcotomic 
cannula  should  not  produce  decubitus,  or  even  erosion  of  the  epithelium. 
Neglect  of  cleanliness  produces  diseased  granulations  that  result  in  build- 
ing up  a  great  mass  of  inflammatory  infiltrate,  which  later  becomes 
fibrous,  and  a  thick  dense  scar  results.  (Operations  for  malignancy  and 
other  conditions  in  the  neighborhood  of  the  trachea  and  larynx  may  cause 
stenosis,  and  in  one  instance  the  author  has  seen  a  compression  stenosis 
in  the  trachea  due  to  cicatricial  contraction  following  a  burn  with  a  band 
of  hot  iron  externally  on  the  neck. 

Attempted  suicide  occasionally  results  in  serious  damage  to  the 
cartilage,  and  if  very  careful  work  is  not  done,  stenosis  may  follow. 
Usually  an  intubation  tube  should  be  worn  in  the  larynx  and  trachea  un- 
til the  wound  inflicted  in  attempted  suicide  has  healed. 

Abscesses  have  been  the  cause  of  the  stenosis  in  two  cases  sent  to 
the  author  for  decannulation.  Xecrosis  of  the  cricoid  cartilage  during 
pneumonia,  in  one  case,  was  the  fundamental  process.  In  the  other 
direct  study  discovered  an  old  abscess  in  the  "party  wall."  Treatment 
of  these  conditions  by  the  direct  method  is  easy,  once  the  lesion  is  located 
but  the  location  is  not  always  easily  determined  unless  careful  search  is 
made.  If  the  original  cords  are  destroyed  by  the  abscess,  good  adventiti- 
ous bands  can  be  formed  in  some  cases  from  the  resultant  scar  tissue 
as  elsewhere  herein  explained. 

Treatment  of  cicatricial  stenosis.  In  deciding  the  method  of  treat- 
ment to  be  used  in  a  given  case,  it  is  very  essential  that  a  very  careful 
bronchoscopic  and  direct  laryngoscopic  examination  be  made  in  addition 
to  ordinary  indirect  laryngoscopy,  \\ith  the  direct  laryngoscope  and  the 
esophageal  speculum  the  party  wall  can  be  accurately  studied.     In  many 


CHUOXIC    STEXOSIS   01'    THE   LARYNX    AND   TRACHEA.  G21 

instances  granulation  tissue  about  the  tracheal  cannula  should  he  removed 
in  order  to  determine  to  what  extent  this  is  a  factor  in  the  stenosis.  Oc- 
casionally a  case  is  encountered  where  the  nature  of  the  stenosis  which 
has  required  a  tracheotomy  has  not  been  determined,  and  where  it  is 
exceedingly  difficult  to  determine  it.  In  some  instances  there  is  nothing 
to  be  seen  but  a  large,  smooth,  rounded  swelling  on  all  sides  of  the 
larynx,  suggesting  tuberculosis,  lues,  or  an  inflammatory  condition.  In 
such  instances,  before  planning  a  procedure,  it  was  at  one  time  necessary 
to  do  an  exploratory  thyrotomy,  but  since  the  development  of  the  direct 
method  where  amijle  specimens  can  be  accurately  taken,  it  is  possible 
to  make  an  accurate  diagnosis  of  conditions,  if  not  of  their  etiology,  in 
every  instance.  A  sliding  punch  forceps  should  be  used  for  this  purpose, 
the  distal  end  being  inserted  between  the  cords  and  a  large  mass  of  the 
tissue  removed,  always  avoiding  injury  to  the  cricoarytenoid  joints. 

The  treatment  of  all  the  different  forms  of  stenosis  is  much  the  same 
if  cicatrices  have  formed.  In  cases  which  have  not  yet  cicatrized,  cica- 
trization must  be  brought  about  liy  excision  of  exuberant  granulations 
and  argyrol  api)lications,  as  the  very  first  step.  The  fungating  granula- 
tions from  necrotic  cartilage  are  particularly  troublesome.  In  these 
cases  the  (|uickcst  and  best  method  is  to  lay  open  the  larvnx  and  trachea 
to  facilitate  drainage  and  resorcin  apjilications.  Such  cases  recjuire  laryn- 
gostomy  anyway,  but  dilatation  must  not  be  commenced  until  the  cartilag- 
inous necrosis  has  ceased  and  healing  is  complete.  In  intubated  cases 
which  show  a  tendency  t(j  close  within  a  few  hours  or  a  few  days  after 
the  removal  of  the  intubation  tube,  ii  is  safer  to  do  a  tracheotomy  and 
remove  the  intubation  tnbf.  In  a  h-w  instances,  however,  it  mav  be 
well  to  try  intubalional  dilatation.  Webs  and  bands  of  cicatricial  tissue 
should  be  excisetl.  Should  intiibational  dilatation  fail,  laryngostomy  will 
cure  almost  e\ery  case.  The  treatment  is  jn-olonged  but  not  painful  and, 
by  the  authorV  method,  the  patient  has  the  use  of  the  whispered  voice 
during  the  entire  treatment. 


CHAPTER    XXXIX. 

Intubational  Dilatation  of  Chronic 
Laryngeal  Stenoses. 

Intubational  dilatation  of  chronic  stenoses  is  advisable  as  the  first 
means  of  treatment  of  all  post  inflammatory  chronic  laryngeal  stenoses. 
It  is  also  indicated  when  there  is  a  slight  recurrence  of  stenosis  after  ap- 
parent cure  by  larvngostomy.  It  is  best  adapted  to  comparatively  recent 
cases  in  which  there  is  not  a  thick  deposit  of  cicatricial  tissue.  Theoret- 
ically, it  should  yield  better  results  than  it  does  clinically,  because  the 
longer  cicatricial  ti.'^sue  is  held  on  the  stretch  the  less  tendency  it  has  to 
recur  and  conversely  the  shorter  the  duration  of  the  stretching  the  more 
prompt  the  recurrence.  Its  percentage  of  cures,  however,  is  suf^ciently 
high  to  warrant  giving  it  first  trial.  Deiavan  has  had  a  large  experience 
with,  and  excellent  results  from,  intubation  in  chronic  stenosis.  (  Bib. 
108,  109,  110,  111,  455.)  Emil  Mayer  (Bib.  372)  and  A\'.  Kelly  Simp- 
son (Bib.  49S)  have  had  excellent  results.  All  of  these  reports  show 
that  great  patience  and  prolonged  treatment,  usually  a  number  of  years, 
are  necessary  for  results. 

Intubational  dilatation  should  not  be  used  in  post-intubational  post- 
diphtheritic subglottic  edema,  because  this  form  of  stenosis  yields  more 
readily  to  the  author's  method  of  galvano-cauterization  (q.  v. )  Intuba- 
tional treatment  is  not  satisfactory  when  tracheal  stenosis  coexists  with 
the  laryngeal  stenosis.     Laryngostomy  is  preferable  for  such  cases. 

Intubation  tubes  and  instruments.  To  be  of  any  benefit  in  cicatri- 
cial cases  dilatation  must  be  prolonged,  and  for  this  purpose  nothing 
equals  the  large  size  intubation  tube  modeled  after  the  tube  of  O'Dwyer. 
In  cases  in  which  the  coughing  out  of  the  tube  involves  risk  of  closure 
of  the  larynx  with  serious  dyspnea,  the  subglottic  retaining  swell  must  be 
large,  and  in  most  cases  the  author's  personal  preference  is  for  a  device 
suggested  to  the  author  by  a  ]iatient  with  a  luetic  cicatricial  stenosis. 
It  was  a  great  comfort  to  this  patient  to  know  that  the  tube  could  not  be 
coughed  out,  and  the  author  and  Dr.  I'atterson  have  subsequently  used 


INTriiATKINAI.  nil.ATATKIN  OI-   CIIKONIC   I.AKVNCKAI,  STENOSES.       {i2-i 

the  same  jilan  in  a  minil)i-r  of  otliir  cases  with  similar  good  results.  It  is 
made  of  siher-plated  brass,  which  is  preferable  to  the  hard  rubber.  The 
post-tube  also  has  the  advantage  of  maintaining  a  large  tracheal  fistula 
which  is  a  great  safeguar<l  because  the  jiatient  can  learn  to  spread  the 
wound  orifice  himself  if  need  be.  'The  first  ones  were  made  of  aluminum 
because  of  the  lightness.     liut  as  aluminum  is  corroded  by  boiling  and 


F"--  45.?- — KadiD^rapli  (jf  the  living  patient,  .sliouing  tlic  author's  self  retain- 
ing dilating  intnhation  tube  in  position  in  a  man  of  eighteen  .vcars,  afflicted  with 
post-typhoiil  lar.\ngeal  stenosis. 


even  by  secretions,  we  liaxc  now  abandoned  it  in  fa\or  of  siKered  Ijrass. 
The  author  has  tried  the  wearing  of  soft  rubber  tubes  because  of  the  ef- 
fect of  soft  rubber  in  softening  cicatricial  tissue,  but  as  the  procedure 
is  not  safe  without  tracheotomy,  it  is  better  to  do  a  laryngostomy  when 
the  effect  of  soft  rubber  is  desired.  <  )tir  screw-post  tube  was  illustrated 
(Fig.   I.").'!)  in  the  Laryngoscope,  .September.   1!i()!i,  without  knowing  that 


G24        INTUBATIONAL  DILATATION  OF  CHRONIC  LARYNGEAL  STENOSES. 

.Schmiegolow  had  used  the  principle  in  the  tube,  Fig.  434,  in  1894  (Bib. 
480,  481).  John  Rogers  also  developed  a  ver^-  ingenious  self  retaining 
tube  and  his  methods  and  results  are  excellent  (Bib.  455,  456,  457). 
Priority  in  the  self  retaining  principle,  therefore,  rests  with  Schmiegolow, 
and  the  Rogers  tube  antedated  that  of  the  author. 

For  palpatory  insertion  of  his  tubes  (Fig.  455)  the  author  has 
found  the  instrument  shown  in  Fig.  45G  to  be  preferable  to  the  form 
of  instrument  vLsed  by  O'Dwyer.  Parenthetically,  it  should  here  be 
stated  that  the  author  in  referring  to  tubes  and  intubation  instruments 
refers  only  to  such  as  are  used  in  the  dilatatory  treatment  of  chronic 
stenosis  of  the  larynx.  For  dii)htheria  and  like  conditions  the  author 
has  never  seen  any  impro\ement  on  the  original  O'Dwyer  apparatus. 
For  intubation  and  extubation  by  the  direct  method  the  author  uses  the 
instrument  shown  in  Fig.  457. 


Fig.  454. — Self   retaining   intnhation  tube  of  Sclimiegelow  (Bib.  480,  481.) 

I ntnhation  and  extubation.  The  method  of  ])alpatory  introduction 
is  precisely  the  same  as  taught  by  O'Dwyer  and  fully  described  and  il- 
lustrated in  the  text  books.  In  children  palpatory  introduction  is  quite 
easy  but  in  adults  it  is,  in  some  cases,  quite  difficult  until  after  much 
practice.  The  larj'nx  is  usually  so  far  down,  especially  when  the  patient 
is  retching,  that  the  arytenoids  cannot  be  reached  by  the  finger,  and  in 
many  cases  these  landmarks  have  been  destroyed  by  previous  necrosis. 
The  right  aryepiglcttic  fold  is  generally  present  in  some  form  and  will 
serve  as  a  palpatory  landmark.  The  direct  method  of  intubation  is 
usually  quite  satisfactory  though  the  supraglottic  swell  of  the  large  adult 
tubes  will  not  go  through  any  but  an  open  laryngoscope.  No  special  in- 
strument is  necessary  for  extubation.  The  post  is  unscrewed  and  re- 
moved, and  then  the  tube  is  pushed  up  into  the  pharynx  with  a  hemostat, 
being  careful  not  to  scratch  the  tube.  The  ])atient  can  usually  eject  the 
tube  from  the  pharynx,  but,  if  not,  the  neck  of  the  tul)e  can  be  seized  in 
the  pharynx  with  the  operator's  first  and  second  fingers. 

Care  of  patients  under  intnbational  treatment  for  hiryn(/eal  stenosis. 
The  tendencv  of  an  intubation  tube  in  the  intnbational  treatment  is  to 


INTI-RATIONAL  DILATATION  OF  CHRONIC  I.AKVNGICAL  STP.NOSES.       625 

sink  lower  and  lower  and  also  to  bury  itself  below  the  epiglottis  anterior- 
ly. This  must  be  combatted  at  first  by  the  support  afforded  by  the  block 
(C,  Fig.  455)  and  later  by  keeping  the  tube  up  into  its  place  with  gauze 
packing  below  the  post  in  the  cervical  fistula.  The  post  must  be  screwed 
tightly  with  a  hemostat  to  prevent  its  accidental  unscrewing.  The  block 
(C,  Fig.  4.-)5)  is  usually  dispensed  with  after  the  establishment  of  a  long 
well  epidermatized  trough. 

It  is  quite  essential  that  the  tubes  shall  be  of  large  size  and  that 
they  shall  be  worn  constantly.     The  size  should  be  increased  up  to  the 


Fig.  455.— The  author's  self  retaining  intubation  tube  for  the  treatment  of 
chronic  laryngeal  stenosis.  The  tube  (A)  is  introduced  through  the  mouth,  then 
the  post  (B)  is  screwed  in  through  the  tracheal  wound.  Then  the  block  (C)  is 
slid  into  the  wound,  the  square  hole  in  the  block  guarding  the  post  against  all 
possibility  of  unscrewing.  If  the  threads  of  the  post  are  properly  fitted  and  tightly 
screwed  up  with  a  hemostat,  however,  there  is  no  chance  of  unscrewing  and  gauze 
packing  is  used  instead  of  the  block  to  maintain  a  large  fistula.  The  shape  of  the 
intubation  tube  has  been  arrived  at  after  long  clinical  study  and  trials,  and  cannot 
be  altered  without  risk  of  falling  into  errors  that  have  been  made  and  eliminated 
in  the  development  of  this  shape. 

point  where  it  requires  a  slight  degree  of  force  for  insertion.  Great  care 
must  be  taken,  however,  not  to  increase  size  too  rapidly  nor  to  carry  it 
too  far.  lest  chondrial  necrosis  set  in  and  make  matters  worse  than  be- 
fore. T'sually  once  a  month  is  often  enough  to  substitute  the  next  larger 
size.  The  tube  must  be  removed  for  cleansing  every  alternate  day  at 
first.  After  a  few  weeks  the  duration  may  be  increased  until  it  can 
remain  in  a  week  or  even  two  weeks.  Should  swelling  and  tenderness 
develop  aroimd  the  wound  the  tube  should  be  removed  and  cleansed. 
Shdiild  the  inflammatory  signs  persist  it  may  be  necessary  to  substitute 


G2C, 


INTUBATIONAL  nil.. STATION'  (11"  CHRONIC   I.AKVXGKAL  STKNOSKS. 


a  trachcotomic  cannula  for  a  few  days.  Tlie  position  of  the  supraglot- 
lic  swell  of  the  tube  should  bo  watched  daily  jircfcrably  by  the  laryngeal 
mirror.  Overhanging  granulations,  if  any,  should  be  removed  with 
tissue  forceps,  Fig.  35,  by  the  direct  method.  Once  every  week,  when 
the  tube  is  removed,  a  bronchoscope  should  be  passed  to  note  progress 
and  to  remove  deeper  granulations,  treat  ulceration  by  applications,  or 


Fk;.  456.— Introducer  for  the  author's  self-retaining  intubation  tubes,  when  it 
if  desired  to  use  the  palpatory  method  of  introduction.  This  instrument  is  for 
adults.  For  children  the  O'Dwyer  principle  is  preferable,  if  an  indirect  instru- 
ment is  desired. 


Fui.  45;. — Introducer   for   placing  the   author's  intubation   tulies   by   tlie   direct 
method.     For  children  the  introducer  of  Mosher  is  better. 


by  change  of  tubal  shape,  or  b\-  temporary  tubal  discontinuance  as  may 
be  indicated.  For  this  inspection  the  bronchoscope  should  always  be 
passed  through  the  !ar\n.\;  thus  the  approach  is  in  what  should  be 
the  normal  laryngeal  and  tracheal  axes.  In  no  case  should  the  tracheal 
fistula  be  allowed  to  close  while  the  patient  is  under  intubational  dilata- 
tion of  a  chronic  laryngeal  stenosis.     Should  an  intubation  tube  become 


INTUBATIONAI.  DII.AI'ATIOX  Ol'  ("ilUDMC   I.AkVXCKAI.  STI^NOSiCS.       (327 

i'ljstnK-t(.'(l  suddenly  a  good  traclical  nurse  can  (.-xtubatc  tlic  patient  liy 
tlie  method  descriljed,  and  if  needed  for  lirealhing,  insert  an  ordinary 
traclieotomic  cannula  temporarily. 

I'rom  time  to  time,  after  the  first  few  months,  the  tuhe  may  he  left 
out  for  a  few  hours  to  note  with  the  mirror  and  hy  the  breathing  what 
gain  is  being  made  in  the  area  of  cross  section  of  the  laryngeal  lumen. 
The  duration  of  the  extubation  test  period  may  be  increased  if  the  im- 
])rovement  warrant,  until  finally  the  tube  can  be  abandoned  altogether. 
The  supreme  test  is  the  breathing  at  night.  When  this  is  quiet  without 
the  tube  the  patient  is  a  probationary  cure,  llis  larynx  must  be  watched 
and.  if  need  be.  intubation  resumed  before  his  larynx  gets  too  much 
contracted.  Six  months  without  the  tube  may  be  called  a  cure.  Fortun- 
ately the  fistula  will  usually  stay  patent  during  this  time  because  it  is 
epithelialized  with  dermal  eiiilhclinni,  1 1'  it  show  an\-  tendencv  to  close 
comi)letely  it  must  be  kej)!  open  by  the  wearing  of  an  obturator,  which 
consists  in  a  silver  iilug  long  enough  barelv  to  reach  the  trachea,  the  plug 
being  metallicall,  attached  to  a  ta])e  holder  after  the  manner  nf  a  tracheo- 
tomic  cannula. 

'I'he  treatnf.-iit  may  recpiire  'rcjni  three  months  to  fdur  years.  Dur- 
ing this  time  the  patient  has  a  good  whispered  voice  but  cannot  phonate. 
He  can  attend  to  any  work,  even  hard  labor,  provided  his  work  dues  not 
re(|uire  a  voice;  and  provided  he  could,  in  cise  of  emergency,  extubate 
himself  and  |iul  in  a  traclieotomic  cannula.  In  miK'  a  few  cases  is  the 
secretion  of  such  a  nature  as  to  bring  about  such  ,in  emergency  after  the 
first  three  or  four  months  of  treatment.  A  few  patients  are  afflicted  with 
a  tubal  accumulatior  of  a  thick,  gummy,  adherent  secretion  which  they 
cannot  cougii  out  of  the  tube. 

The  ultimate  vocal  results  in  the  successful  cases  is  excellent  in  ])ro- 
jiortion  as  aryti-noid  motility  remains.  In  ankylotic  and  necrotic  aryte- 
noid conditions  the  |>;itient  will  get  a  loud  thnugh  rou.uli  and  intlexible 
phonation.  .Many  patients  ac<|uire  a  peculiar  sidewise  dip])ing  of  tlie 
head,  with  working  of  tlie  ])latysnia  myoides  and  other  cervical  muscles 
just  as  they  commence  to  sjjeak.  The  ultimjite  voice  in  ;idults  is  usually 
lower  in  pilch  than  before  treatment.  In  children  time  will  work  won- 
ders in  the  de\elo;'ment  of  flexible,  alnio-;t  unimpaired  voice. 


CHAPTER     XL. 

Laryngostomy. 

Definition.  L;)ryngostomy  is  the  name  given  to  the  surgical  pro- 
cedure of  laying  onen  the  larynx  anteriorly  and  keeping  it  open  for  a  long 
period  of  treatment.  ]\Iore  or  less  of  the  trachea  is  usually  included  in 
the  opening  and  the  procedure  is  then  laryngotracheostomy. 

History.  It  was  done  for  steno-is  first  by  Heryng  in  1894  (Bib. 
215)  and  by  Ruggi  for  recurrent  papilloma  in  1S!)8  (Bib.  461).  It  has 
since  been  elaborated  and  developed  by  Sargnon  (Bib.  472,  473,  474), 
Canapel,  Melzi,  Cagnola,  Barlatier,  Baratoux,  \'ignard  and  others.  Sarg- 
non's  methods  and  results  are  especially  worthy  of  study. 

The  author  first  performed  it  in  ]!NiO,  reporting  five  successful 
cases,  with  exhibition  of  two  of  the  patients  at  the  meeting  of  tlie  Ameri- 
can Laryngologiral.  Rhinological  and  Otological  Society,  February.  1904. 
(Bib.  268).  In  these  cases  the  author  used  the  T-shaped  silver  cannula 
shown  at  A  and  B,  in  Fig.  458,  and  a  laryngostomy  cannula  (Fig. 
459).  In  two  of  the  cases  the  stenosis  subsequently  recurred.  In  19(i6 
Killian  demonstrated  a  vastly  better  method  by  post-operative  dilatation, 
that  made  of  laryngostomy  an  operation  that  has  now  a  permanent  place 
in  the  surgery  of  the  larynx.  He  also  made  use  of  a  T-shaped  cannula 
(C,  Fig.  458),  but  it  was  made  of  soft  rubber  and  was  used  in  successively 
increasing  sizes  for  dilatation.  He  had  discovered  that  the  contact  and 
elastic  pressure  of  tiie  soft  rubber  caused  a  softening  and  absorption  of 
the  obstructive  endolaryngeal  tissue.  Taking  advantage  of  the  ei?ect  of 
the  contact  of  rubber  tubing,  the  author  fitted  the  rubber  tubing  in  in- 
creasing sizes  .nnd  of  proper  length  for  the  particular  case  (Figs.  461 
and  475)  over  the  upnglit  branch  of  his  old  laryngo'itomy  cannula.  (Fig. 
459^.  The  results  of  this  have  been  ideal.  Sargnon  suggested  tying  the 
rubber  drain  to  an  ordinary  cannula  as  shown  in  Fig.  462.  Under  his 
skilful  care  this  i)ro(luced  excellent  results,  but  in  the  hands  of  others 


LARYNCOSTOMV. 


(32!) 


great  care  has  liecii  necessary  to  combat  its  tendency  to  the  development 
instead  of  the  ohhteration  of  the  si>ur  ( K,  Fig.  4(iO),  which  all  old  can- 
nula wearers  have.  Fournier  suggested  using  an  ordinary  tracheotomic 
cannula,  the  tubing  ha\ing  a  side-opening  through  which  the  cannula 
was  placed.  This  also  produced  good  results,  but  it  does  not  obliterate 
the  spur  (E,  Fig.  460)  like  the  author's  apparatus.  Fig.  4(J1.  Mr. 
Walter  G.  Howarth  has  had  excellent  results  from  dispensing  altogether 
with  a  cannula.     (Fig.  4G4).     The  rubber  tubing  is  cut  long  enough  to 


Fig.  458. — A.  B.,  T-shaped  separable  tracheal  cannula  of  the  author.  Each 
section  is  inserted  separately,  then  the  two  arc  held  together  by  the  ring.  (Bib. 
268).  The  tape  liolder  retains  the  tube  and  dressings.  C,  T-sliaped  soft  rubber 
tube  of  Killian. 


Fk;.  459.— .Xuthor's  laryngostomy  cannula  originally  used  without  rubber  tubing. 
After  Killian's  discovery  of  the  effect  of  rubber  dilatation,  rubber  tuliing  in  increas- 
ing sizes  and  of  proper  length  has  been  placed  over  the  upright  branch  tube,  as 
shown  in  the  radiograph.  Fig.  475,  and  the  schema,  Fig.  4O1. 


extend  down  the  tracliea  past  tli-:  iistula  and  is  held  in  place  by  ligatures 
wiiich  are  fastenol  to  the  middle  of  the  tubing,  opposite  the  fistula,  by 
passing  the  sutures  through  the  wall  of  the  tubing  with  a  needle,  before 
the  tubing  is  put  m  place.  This  method  seems  excellent,  and  is  readily 
placed  without  di.scomfort  to  the  patient.  Thosi  does  not  use  the  soft 
rubber  softening  and  absorbing  method.  He  inserts  a  smooth,  hard-rub- 
ber plug,  or  wedge,  above  the  ordinary  tracheal  cannula  as  shown  in 
Fig.  4fi(!.     Flis  results  are  excellent.     Much  careful   work,  however,  is 


G30 


LARYNGOSTOMY. 


_^ 


Fig.  460. — Schematic  representation  of  the  problem  involved  in  laryngeal 
stenosis  when  the  patient  has  been  wearing  a  cannula  for  a  long  time.  In  addi- 
tion to  the  original  stenosis  (L)  in  the  larynx,  the  wearing  of  the  cannula  (C) 
has  built  up  the  stenotic  mass  (E)  in  the  trachea.  S  represents  the  skin  and 
T,  TT,  represent  the  trachea. 


Fig.  461. — Schema  showing  the  author's  method  of  laryngostumy.  The  hollow 
upward  metallic  branch  (N)  of  the  cannula  (C)  holds  tlie  rubber  tube  (R)  back 
firmly  against  the  spur  (^E)  on  the  back  wall  of  the  trachea.  Moreover,  the  air 
passing  up  through  the  rubber  tube  (R),  permits  the  patient  to  talk  in  a  loud  whis- 
per, the  external  orifice  of  the  cannula  being  occluded  most  of  the  time  with  the 
cork   (K). 


Fig.  462. — Schema  i-howing  tlie  method  of  Sargnon  for  after-treatment  of 
laryngostomy.  Excellent  results  have  followed  this  method.  The  tendency  of  the 
cicatricial  spur  (E)  to  push  forward  the  lower  end  of  the  rubber  tube  (R)  should 
be  combated.  The  tubing,   K,  is  plugged   vvitli  gauze  at  each  dressing. 


LARi'NGOSTOMY. 


031 


needed  to  combat  the  spur,  shown  at  E,  Fig.  4()0.  The  patient  has  not 
even  a  whispered  voice  while  the  pkig  is  in  place,  but  doubtless  this  could 
be  remedied  l)y  an  air  canal  in  the  plug. 

Indications.  \\  hen  all  else  fails  in  a  case  of  cicatricial  stenosis,  re- 
course must  ')e  had  to  laryngostomy,  and  with  ])ropcr  patience  in  carry- 
ing out  the  treatment,  it  will  cure  every  case  unless  the  loss  of  cartilage 
is  very  e.xtensive.    Formerly,  in  the  stenosis  due  to  chronically  recurring 


Fig.  46,v — Fournier's  method  of  holding  the  rubber  dilatatory  drain  in  posi- 
tion. B,  rubber  drain  with  side  opening  cut  in  lower  end.  A,  tracheal  cannula 
attached  to  drain  by  passing  the  tube  of  the  cannula  through  the  side  hole  of  the 
rubber  drain,  where  it  is  held  by  two  ends  of  a  suture  to  the  staples  of  the  tape 
plate.     The  tubing  is  plugged  with  gauze  at  each  drcsshig. 


Fic.  464. — Method  of  Mr.  Walter  G.  Howartli  in  laryngostumy.  The  cords 
(H,  H)  transfixed  through  the  wall  of  the  rubber  tubing  (R).  After  tlie  tube  is 
in  place  in  the  larynx  and  trachea  the  free  ends  of  the  cords  are  tied  over  the 
large  plug  of  gauze  that  is  forced  into  the  laryngostoiny  opening  in  the  effort  to 
keep  this  opening  as  large  as  possible. 


|iapillumata  in  children,  the  author  resorted  U)  laryngoslomy  in  iiuract- 
ahle  cases,  but  since  perfecting  the  technic  of  direct  removal,  he  has 
found  that  by  persistence  with  the  extirpation  and  alcohol  ai)|)lications.  it 
is  possible  ultimately  to  cure  every  case.  There  are  a  number  of  stenotic 
conditions  such  as  scleroma  that  doubtless  would  be  benefited  by  laryn- 
gostoniv,  but  the  author  has  had  no  personal  exjierience  with  tlu-m. 


632 


LARYNGOSTOMY. 


C OHtraindicatwns.  Pyrexia  is  an  absolute  contraindication.  Active 
lues  and  active  tuberculosis,  local  or  elsewhere,  do  also.  Bronchial  and 
pulmonary  disorders  greatly  increase  the  risks  and  if  irremediable,  they 
are  contraindications.  Serious  organic  disease  anywhere  is  prohibitive. 
Excessive  loss  of  laryngeal  and  tracheal  cartilage  will  preclude  a  success- 
ful result.  A  purulent  focus,  as  in  the  nasal  accessory  sinuses,  increases 
the  risk  but  is  not  an  absolute  contraindication. 


Ck 


H^ 


T 


Fig.  465. — Special  rubber  tube  of  Moure  for  laryngostomy.  The  tubular  parts 
(L  and  T)  are  in  the  larynx  and  trachea,  respectively,  while  the  loops  (M,  M) 
project  through  the  external  wound  to  keep  it  patulent. 


Fig.  466.— Thost's  apparatus  for  the  dilatation  of  cicatricial  laryngeal  stenosis. 
The  hard  rubber  plug,  B,  is  inserted  from  below  upward  before  the  ordinary 
tracheal  cannula,   C,  is  inserted. 


Instntmcnts.  Besides  general  operating  instruments,  the  reciuisites 
are  a  blunt  pointed  bistoury,  Moure's  thyrotoniy  shears  or  the  turbino- 
tome (Fig.  467),  small  retractors,  silk  for  suturing  the  mucosa  to  the 
skin.  As  in  all  external  laryngeal  surgery  a  small  electric  light,  worn  be- 
tween the  operator's  eyes  (not  on  top  of  the  head)  is  essential.  The 
illuminating  and  the  visual  axes  must  almost  coincide.  For  the  post- 
operative  dilatatory   dressings,   soft   rubber   tubing  evenly   graduated   in 


LARYNGOSTOMY. 


0:5:3 


sizes  from  ].")  to  4.j  French  scale  sizes  is  needed.  These  are  unobtainable 
in  drainage  tubinjj,  but  veterinary  catheters  answer  admirably.  These 
tubes  must  be  cut  in  length  to  suit  the  case,  the  cut  edges  being  rounded 
with  sand  paper  or  by  singeing  in  the  flame  of  an  alcohol  lamp,  being 
careful  not  to  burn  the  ruViber,  only  to  melt  otT  the  sharp  angle  of  the 
cut  edge. 

Preliminurics.  The  patient's  health,  if  improvable,  must  be  im- 
proved. Luetic  cases  should  have  at  least  one  month's  treatment,  whether 
active  lesions  are  present  or  not.  As  in  all  operations  about  the  air 
passages,  the  mouth  and  teeth  should  be  put  in  the  best  possible  condi- 
tion with  the  aid  of  the  dentist  if  necessary.  Alcohol  "2.")  per  cent 
strength  is  the  best  non-toxic  antiseptic  mouth  wash.  All  proprietary 
preparations   are  a  delusion,   unless   they  contain   alcohol ;   though   they 


Fig,  467. — Tiirliinotomc  of  the  author,  originally  devised   for  turbinotomy  but 
found  excellent  for  thyrotomy  and  laryngotomy. 


may  be  used  to  flavor  the  wash.  Diseased  tonsils  should  be  removed 
radically  and  healing  awaited. 

Position  of  the  patient.  The  patient  is  placed  in  the  combined 
Trendelenberg-Rose  position  to  prevent  aspiration  of  blood  and  secre- 
tions. If  the  wound  be  not  allovv-ed  to  close  during  the  operation,  the 
retractors  being  always  kept  in  place,  the  blood  cannot  be  aspirated  up 
hill.  If  the  edges  of  the  wound  be  allowed  to  a])proximate  there  is  no 
longer  an  ojjcn  trough,  but  a  tube,  continuous  with  the  trachea,  up  which 
fluids  can  be  aspirated. 

.■Anesthesia.  Local  infiltration  anesthesia  is  far  the  best  and  safest 
anesthetic.  The  solution  we  use  is  the  same  as  for  tracheotomy  ( c|.  v.). 
The  intradermatic.  nftl  hy])()dermatic,  injection  of  this  solution  along  the 
line  of  incision,  will  produce  absolute  analgesia  of  the  skin  and  partial 
anesthesia  of  scar  tissue.  The  interior  of  the  larynx  can  be  anesthetized 
in  adults  by  the  local  swabbing  with  a  "iO  per  cent,  cocaine  solution.  This 
must  be  ai)plie(l  throu!.'h  the  tracheal  fistula  before  commencing  to  oper- 


(;34 


LARYNGOSTOMV. 


ate.     It  will  have  no  effect  afterward.     The  only  really  painful  part  is 
the  thyrotomic  clip  (Fig.  4()8)  and  this  is  over  in  an  instant. 

Operatioyi.     For  clearness  the  operation  may  be  described  in   four 
steps : 

1 .  Opening  of  the  larynx. 

2.  Incision  of  the  posterior  wall. 

3.  Suture  of  the  mucosa  to  the  skin. 

4.  Placing  of  the  dilating  tube  and  the  dressing. 

].  Laryngotomy.  This  step  is  described  as  dividing  the  tissues 
layer  by  layer,  skin,  cellular  tissue,  fascia,  thyroid  gland,  etc.  Such  pro- 
cedure is  a  great  waste  of  time.  The  simplest  method,  re(|uiring  Init  a 
second  or  two,  is  to  insert  the  lower  blade  of  the  inverted  turbinotome 


Fig.  468. — Turbinotumc  111  pu.-iition  to  make  the  thyrotomic  clip.  The  table  is 
not  shown  steeply  inclined  toward  the  head  as  it  should  be  before  the  turbinotome 
is  inserted. 


(Fig.  4(>T  )  in  the  tracheal  fistubi,  as  shown  in  Fig.  Kl.s.  and  to  divide 
all  the  tissues,  including  tlie  skin,  at  one  clip.  The  incision  must  always 
extend  to  the  tracheotomic  fistula,  no  matter  how  low,  in  order  that  all 
the  conditions  within  to  be  dealt  with  may  be  exposed  to  view  and  treat- 
ment. Thi.s  applies  with  especial  force  to  the  granulatory  or  hyper- 
plastic spur  (  E,  Fig.  4(!0),  which  is  so  often  a  factor  in  i)reventing  de- 
cannulation.  In  making  this  clif)  in  cases  in  which  the  thyroid  cartilage 
has  been  divided  before,  as  is  often  the  case  in  the  cases  that  come  to 
the  author,  great  care  should  be  taken  to  follow  the  line  of  fibrous  imion. 
The  thyroid  cartilage  rarely,  if  ever,  unites  with  cartilaginous  tissue,  and 
the  island  of  cartilage  (E,  Fig.  4()9)  produced  by  a  cut  in  a  new  location, 
is  very  likely  to  die.  This  is  a  disaster  because  it  diminishes  the  already 
deficient  size  of  the  larvngeal  framework. 


I.ARYNC.HSTOMY. 


G35 


2.  Incision  of  the  posterior  Tiv;'/  is  hesl  iloiu-  with  a  sharp  scalpel, 
vertically,  exactlv  in  the  mctliaii  line,  clear  ihrou^'h  the  scar  tissue,  hut 
with  great  care  not  to  incise  the  anterior  esophageal  wall.  In  intubated 
cases  the  scars  are  usually  on  the  posterior  wall  in  the  cricoid  region, 
and  they  should  be  di\ided  through  to  the  cartilage;  remembering,  of 
course,  that  above  the  cricoid  cartilage  the  posterior  laryngeal  wall  is 
soft,  othervk-ise  the  esophagus  might  be  penetrated.  Xow  we  come  to 
the  essential  technical  improvement  of  Killian.  Instead  of  excising  the 
cicatricial  tissue,  and  eviscerating  the  larynx,  he  took  advantage  of  the 


Fig.  469. — Scliema  sliowiiig  error  to  avoid  in  opening  tlie  larynx  in  any  case 
in  vvliicli  llie  thyroid  cartilage  has  been  previously  divided.  If  the  new  incision 
(as  at  C,  D)  does  not  follow  the  line  of  tibrous  union,  A,  B,  the  island  of  cartilage, 
E,  will  likely  become  necrotic,  still  further  narrowing  the  larynx  and  rendering 
c'.ire  extreinelv  difficult. 


Fig.  470. — Author's  grasping  forceps  for  external  laryngeal  operations.  They 
hold  firmly  large  or  small,  protrud.ng  or  flat  tissues,  and  do  not  tear  out  like  all 
forms   (if  toothed   forceps   do. 


tendency  oi  the  tissues  to  absorb  and  melt  away  under  the  contact  and 
elastic  pressure  of  soft  rubber  tubing.  The  linear  median  incision  is  to 
form  a  trench  in  wbii'li  to  lay  the  tube.  Lateral  cicatrices  are  not  in- 
cised, but  left  to  disappear  in  the  |'ost-(jperati\  e  treatment.  Sargnon  and 
1'arlatier  ,'id\ise  excision  in  cases  of  limited  membranous  cicatrices,  plug- 
ging the  womid  lor  a  few  days  with  \aselineil  g;mxe.  In  some  cases 
the  author  has  fotind  it  advaiUageous  to  excise  with  curved  scissors  web- 
like cicatrices,  and  also  to  excise  \ery  thick  cicatricial  inllltrations.  thus 
shortening  the  after  treatment.  I'nr  gras]iing  tissues  within  the  larynx 
the   forceps,  I-'ig.    I7<i,  are  the  best. 

1.     Placiiii/  (if  the  (lilatiiii/  tube,  the  cannula  ami  the  dressiiij/.     'I'he 
l)atient  is  now  asked  to  cotigh,  it.  indeed,  he  has  not  been  coughing  freely. 


63G 


I.ARYXCOSTOMY. 


If  the  reader  uses  general  anesthesia,  he  is  urged  never  to  have  the 
patient  so  deeply  under  that  the  tracheal  cough  retiex  is  completely  abol- 
ished. The  laryngeal  cough  reflex  may  be  more  or  less  controlled  as 
desired  by  the  preHminary   use  of  cocaine.     The  tracheal  cough   reflex 


Fig.  4/1. — Photograph  of  wound  immediately  after  laryngostomy,  before  the 
placing  of  the  cannula,  rubber  dilating  tulje,  dilatatory  drain,  and  dressings.  The 
silk-worm  gut  sutures  uniting  the  skin  to  the  lining  of  larynx  have  hemostats 
attached  to  them.  The  suture  ends  were  cut  off  afterw-ard. 


Flu.  472.— RublK-r  tube  and  cannula  in  place  ready   f.ir  the  application  of   the 
dressings. 


is  the  watch-dog  of  the  lungs,  as  the  author  has  so  often  urged,  and 
should  never  be  abolished  in  the  surgerj-  of  the  air  passages.  The  rub- 
ber dilating  drain  is  now  cut  to  length.  It  should  extend  upward  as  high 
as  possible   without   interfering   with   epiglottic   closure  and   downward 


I.ARYNGOSTOMY. 


637 


over  all  of  the  vertical  liraneh  <it  the  cannula.  Its  ui)i)er  end  is  plugged 
'.vitli  gauze  securely  stitched  to  the  rubber,  lest  it  escape  into  the  trachea. 
The  two  ends  of  a  braided  silk  cord,  previously  transfixed  through  the 
wall  of  the  lower  end  of  the  rubber  tubing  and  tied,  are  now  carried 
outward  and  made  fast,  one  end  to  the  right  and  the  other  to  the  left 
end  of  the  tape  holder  of  the  tracheal  cannula.  They  are  drawn  taut 
in  such  a  way  that  the  soft  rubber  tubing  cannot  slide  upward  off  the 
vertical  branch  of  the  cannula. 

"i.  Siitui'c  of  the  mucosa  to  the  skin.  The  mucosa,  or  the  cica- 
tricial tissue  of  each  lateral  wall  of  the  larynx,  is  sutured  to  the  skin  by 
three  or  more  deeply  ])!aced  silk-v.orm  gut  sutures  which  jiass  through 


Frc.   473. — .\   case  of  laryngostomy   one   month   after  operation.     The  epider- 
matization  of  the  laryngeal  cavity  is  progressing. 


the  laryngeal  lining  and  intervening  tissues  to  and  through  the  skin. 
Superficial  stitches  slough  out  ni  a  few  days.  Care  must  be  taken  not 
to  lacerate  the  edges  of  the  tracheal  or  laryngeal  cartilages.  Preserva- 
tion of  the  cartilage  is  of  jirimary  imjiorlance  in  all  stages.  If  there  is 
no  cicatricial  tissue  at  the  divided  edges  to  support  sutures  they  had 
better  be  dispensed  with,  because  normal  tracheal  or  laryngeal  edges  will 
be  lacerated. 

Tn  placing  the  apparatus  it  must  he  borne  in  mind  that  if  the  tube 
were  U>  slide  ujjward  even  slightly  it  would  ride  above  the  spur  [E, 
Fig.  4<>(i).  'I'he  great  efficiency  of  the  autlior's  method  is  due  to  its 
keeping  the  soft  rublH-r  in  perfect  pressure  contact  with  this  spur,  and 
giving  the  straight  nji  and  down  line  to  the  posterior  tracheal  wall  as 
shown  in  the  radiogra])lis,  Figs.  474  and  475.  In  placing  the  apparatus 
the  rubber  tubing  with  braided  silk  conls  atlaclied  by  suture  to  its  lower 


638 


LARYXr.OSTOMY. 


Fig.  474. — Anteroposterior  radiographic  \ie\v  of  the  author's  laryngostomy  ap- 
paratus in  situ,  in  a  woman  27  years  of  age,  affected  with  post-typhoidal  cicatricial 
laryngeal  stenosis. 


Fig.  475.— Lateral  radiographic  view  of  the  same  patient  as  shown  in  Fig.  474. 


LARYXCOSTOMY. 


iVM 


end,  is  inserted  tliroiit;b  the  laryngostomy  wound  and  pushed  upward  into 
the  larynx,  the  outer  ends  of  the  silk  being  prevented  from  escaping  by 
clamping  a  hemo-"tat  on  them.  The  special  laryngostomy  cannula  is  then 
inserted  into  the  tracheal  trough.  The  rubber  lubiug  is  then  (lulled  down 
and  made  fast. 

With  this,  or  any  other  form  of  ajjparatus.  if  increa.-ed  pressure  at 
one  point  is  desirec'.  the  diameter  of  the  dilating  rubber  tube  may  be 
increased  at  the  corresponiling  point,  as  suggested  by  Sargnon  and  liar- 
latier.  by  slipping  over  the  tube  another  bit  of  tubing  of  the  proper  dia- 
meter to  be  telescoped  over,   an^l   of   a   length   to  correspond   with   the 


Fig.  476. — .\utlior"s  method  of  packing  traclieal  and  external  laryngeal  vvnunds 
tn  keep  tliem  open.  A  double  thickness  of  gauze  is  spread  over  the  whole  front 
of  the  neck.  The  portion  over  the  wound  is  then  tucked  into  the  wound.  Then 
a  little  hard  roll  of  gauze  is  forced  into  the  wound,  carrying  the  double  layer  with 
it.  This  form  of  dressing  prevents  any  ends  from  getting  down  into  the  tracliea. 
Useful  in  dressing  lar\ngostomies,  thyrotomies  and  tracheotomies. 


vertical  extent  of  the  portion  of  the  laryngeal  or  tracheal  lunuii  that 
requires  the  additional  pressure. 

After  the  tube  is  placed  the  gauze  dressing,  in  the  form  of  a  tight 
roll  of  i)ro])er  size,  is  smeared  with  sterile  vaseline,  and  forced  into  the 
wound  in  such  a  way  as  to  keep  it  open.  (Jnr  preference  is  for  the  form 
that  we  use  in  thyrotomy  dressings.     (Fig.    ITfi.) 

After-care.  The  dressing  should  be  changed  every  three  hours,  the 
gauze  being  wrung  out  of  bichloride  of  mercury  1  :l(l,0(i(i  solution.  This 
is  contrarx'  to  routine  surgery,  but  routine  surgery  has  a  high  mortality 
if  applied  to  the  larynx.  Nurses  trained  in  this  laryngeal  .uid  tr.icbcal 
work  attend  to  the  dressing  imdcr  the  supervision  of   Dr.   Mllen  J.    I'al- 


640 


LARYNGOSTOMY. 


terson,  who  dresses  tlie  wound  once  daily  herself.  In  larvngostomies  she 
puts  in  place  the  increasing  sizes  of  dilating  tubes.  If  sloughing  or  too 
great  pain  should  supervene,  it  is  well  to  omit  increasing  the  size  and  let 
the  patient  wear  the  same  size  or  the  next  smaller  size  for  a  week  or 
more,  as  seems  best.  It  is  absolutely  necessary  to  observe  the  utmost 
vigilance  to  prevent  any  loss  of  what  dilatation  has  been  gained.  A  few 
days  without  any  dilating  tube  may  seriously  retard  the  cure. 

After  the  first  few  days,  the  gauze  plug  stitched  inside  the  upper  end 
of  the  rubber  dilating  tube  is  omitted  and  the  patient  can  then  speak  in 
a  whisper,  and  can  breathe  through  the  mouth,  the  external  orifice  of  the 
cannula  being  corked.  This  is  one  of  the  great  advantages  of  the  author's 
method. 

The  success  of  the  operation,  like  all  laryngeal  surgery,  is  dependent 
almost  entirely  upon  the  care,  patience  and  skill  with  which  this  after- 


FiG.  4-7. — Schema  illustrating  the  author's  method  of  hastening  epidermatiza- 
tion  of  a  laryngostomy  wound.  An  incision  through  the  skin  is  made  on  each 
side  as  shown  by  the  dotted  lines,  C,  and  D.  The  skin  is  dissected  loose  from 
the  subcutaneous  tissue  (except  at  the  edges  of  the  laryngostomy  opening)  so  as  to 
allow  it  to  slide.  If  packing  is  put  under  to  prevent  it  healing  back  into  its  old 
position,  it  will  be  found  in  a  few  days  that  the  skin  has  been  drawn  down  into 
the  woimd  as  shown  at  E,  F,  thereby  satisfying  the  tendency  to  contract. 


treatment  is  carried  out.  The  dilatation  should  be  slow,  making  progress 
no  faster  than  the  tissues  will  tolerate.  Sloughing  or  excessive  fetor 
is  a  warning  to  ease  up  on  the  pressure.  The  sloughs  and  exudates  are 
usually  infections  of  buccal  origin.  They  are  usually  thin  and  may  be 
cleared  away  by  mopping  with  hydrogen  peroxid  solution.  They  may 
surround  the  stitches,  which  may  have  to  be  removed  if  the  sphacelic 
process  is  too  severe. 

The  purpose  is  to  get  rid  of  the  cicatricici!  tissue  ami  to  cover  the 
nezL'Iy  formed  lumen  of  the  larynx  first  ziith  small  firm  granulations,  then 
Zi'ith  epidermal  epithelium.  This  must  be  kept  in  mind  in  the  after  care 
as  it  is  the  keynote  to  success.  This  epidermatization  may  take  two 
months  or  longer.  It  is  claimed  by  some  that  some  regeneration  of 
cartilage  takes  place.     In  many  cases  the  wound  seems  to  be  shallower 


LARYNGOSTOMY. 


(Ml 


lhi>ii<;h  larger.  That  i^,  it  is  neaier  tlie  surface  of  the  skin.  A  few  re- 
main deep.  In  tiiese  deep  cases  we  have  found  it  advantageous  to  sHde 
a  section  of  skin  on  each  side  down  into  the  wound  as  shown  in  Fig.  477. 
Where  the  skin  and  subcutaneous  tissue  are  not  too  cicatricial  from  re- 
peated operation  and  the  healing  of  open  granulating  wounds,  this  method 
has  also  been  verj'  efficacious  in  preventing  cicatricial  contraction  in 
shallow  cases.  The  method  will  be  readily  understood  from  Fig.  177 
.\t  .\  and  at  T.  are  seen  the  normal  skin  ed.;es  dipping  down  into  the 


li'..  -17.S. — l-runi  a  ijliutograpli  illustrating;  llif  iik'al  rc-.-ult  in  hirxiigostomy. 
\\'!u-n  the  niter-treatment  has  l)e:n  properly  carried  cuit,  tlie  skin  will  lie  pulled 
dowr.  into  the  wound  in  a  funnel-like  shape  as  here  shown.  It  is  an  elongated 
funnel,  not  a  circular  one.  The  actual  skin  surface  should  he  drawn  in,  not 
sinipl\'  an  epitlielialized  cicatricial  tissue. 


tracheal  wou)id.  To  obtain  tlii'^  dip|>ing  down  of  normal  skin  (not  cica- 
tricial tissue  covered  willi  e]ii(Krnial  epitlicliinin  it  is  necessary  to  have 
normal  skin  to  bei^in  with,  and  llie  p'issibility  of  obtaining  this  will  de- 
pend somewhat  upon  the  ])osition  of  the  original  tracheotomy.  If  the 
laryngostomy  has  gone  llirnugii  perfcctlv  normal  skin  and  the  after-pack- 
ing has  been  carefully  attended  to,  the  skin  surface  should  (lij)  down 
into  the  wound  as  shown  at  .\.  I'..  l'"ig.  177,  and  in  the  phologra|)h.  I"ig. 
■I7S.     If,  however,  granulations  h,a\e  been  allnwed  to  rise  higher  than  the 


643 


LARYXGOSTOMY. 


edges  of  the  skin  the  object  will  be  defeated.  But  having  obtained  the 
condition  shown  in  Fig.  478,  the  author's  method  of  preventing  contrac- 
tion has  yielded  excellent  results.  Not  only  does  it  satisfy  the  tendency 
of  the  cicatricial  tissue  to  contract  but  it  also  furnishes  a  good  dennal 
lining  for  the  trachea,  or,  rather,  for  the  new  adventitious  lumen  that  is 
to  supply  the  place  of  the  old  stenosed  trachea. 

Epidermatization  is  favored  by  the  use  of  a  ten  per  cent  ointment  of 
scarlet  red. 


Fig.  479. — Schema  of  the  autoplastic  operation  of  Berger  for  closing  a  tracheo- 
dermal  fistula.  A,  elliptic  incisions  around  the  fistula.  B,  flaps  turned  epidermis 
inward  and  sutured.    C,  manner  of  drawing  together  and  suturing  the  skin  to  cover 

the  flaps.     C.-Kfler  Molinie). 


Fig.  480. — Schema  of  the  autoplastic  operation  of  Gluck  for  the  closure  of  a 
tracheo-dermal  fistula.  A,  form  of  incisions  and  flaps,  one  on  each  side  of  the 
fistula.  B,  one  flap  turned  back  and  sutured,  epidermal  surface  inward.  C,  the 
other  flap  dragged  over  to  close  the  wound.     (After  Molinie.) 

Duration  of  the  treatment  -".aries  from  three  to  six  months,  oc- 
casionally longer.  At  the  end  of  this  time,  it  is  in  most  cases  possible  to 
close  the  laryngostomy  by  a  plastic  operation,  but  it  is  better  not  to  do 
so.  No  matter  how  promising  the  result  appears,  the  small  opening 
should  be  allowed  to  remain  patulous  for  a  few  months  longer  to  facilitate 
the  watch  for  recurrence.  In  rare  cases  a  number  of  years  have  been 
required  for  complete  cure.  Xo  case  should  be  called  cured  until  six 
months  have  elapsed. 

Aittof<lasty.  The  laryngostomy  ojiening  will  rarely  unite  without 
autoplasty  because  of  its  epidermatization.  When  autoplasty  is  required, 
the  Berger  or  Gluck  operations,  clearly  shown  in  Figs.  479  and  480, 
will  usually  close  the  opening  perfectly,  though  a  number  of  minor  sec- 


I.AKYXGOSTOMY. 


643 


ondary  operations  are  at  times  iiecessar)-  to  close  little  tistnlae  which  oc- 
cur, usually  at  the  corners  of  the  flaps.  Like  all  plastic  operations,  suc- 
cess depends  uj^on  large  well  nourished  flaps,  placed  without  too  much 
tension.  It  is  necessary,  in  males,  to  modify  the  shape  of  the  flaps  to 
avoid  if  possihle  the  turning  in  of  skin  bearing  coarse  hair.  The  outer 
surface  of  the  skin  Hap  is  always  turned  in  toward  the  trachea.     In  one 


Fk;.  481. — I'Voni  a  ]ilirU'igr,-L(il)  oi  a  i>atioiit  taken  two  \L-ars  aflcT  cniiipU'te 
cure  of  obstinate  cicatricial  post-typhoid  laryriRotraclical  stenosis,  by  laryngostomy. 
(Four  years  have  elapsed  since  complete  cure  and  plastic  closure.  Voice  and 
breathing  arc  excellent.  I'alicnt  was  originally  tracheotomizcd,  in  cxlmiiis. 
by  Dr.  Joseph  II.  Barach). 

of  our  cases,  three  plastic  operations  failed  to  close  a  fistula.  The  entire 
front  of  the  neck  was  a  mass  of  scar-tissue.  After  each  operation,  a  small 
fistula  would  jiersist.  We  discovered  that  it  was  the  ])ressure  during 
cough  that  forced  a  small  (ijiening  and  forced  the  secretion  out,  thus 
causing  a  leak.  I!y  doing  a  tracheotomy  very  low  in  the  neck,  the  pres- 
sure on  the  olastic  above  at  the  site  of  the  laryngostomy  during  coughing 
was  completeh'  i)revenled.     .After  healing  of  the  laryngostomy  opening 


644 


LARYXGOSTOMY. 


was  complete,  the  cannula  below  was  removed  and  the  lower  wound 
packed  in  the  usual  way  until  it  closed  from  the  bottom  up.  This  new 
tracheal  wound,  not  being  epiderm.atized,  healed  in  about  ten  days.  This 
patient,  now  four  years  after  complete  closure  and  six  years  after  the 
lumen  was  enlarged  to  the  desired  point,  remains  absolutely  free  of  ste- 
nosis and  has  now  a  good,  though  rough,  voice.  Figure  481  was  made 
from  a  photograph  taken  two  years  ago.  In  some  instances  we  took  the 
tension  off  th.e  plastic  stitcher  by  the  use  of  the  lacing,  Fig.  482. 


Fig.  482. — Lacing  adhesive  strips   for  lessening  the  tension  on  the   sutures  ot 
autoplastic  flaps. 


p 

1 

^. 

\, 

i 

« 

1 

t     'TM 


Fk..  4,S_i. — lUiisUauiig  iIk-  riMilt  ui  L^^^ll,l.;'.■^l"ln.*  hi  a  boy  o£  sixteen  years.  A, 
post-typhoid  laryngeal  stenosis.  The  entire  subglottic  region  is  filled  with  inflam- 
matory tissue,  li.xing  the  cords.  B,  laryngostomy  tube  in  situ.  C,  after  four 
months'  treatment  with  the  author's  apparatus.  D,  two  years  after  the  tracheal 
fistula  was  closed  by  autoplasty.  (Laryngeal  mirror  views  sketched  from  life  by 
the  author.) 


Results.  Of  the  author's  eighteen  cases,  two  are  still  under  treat- 
ment. Two  were  cured  by  laryngostomy  without  dilatation,  two  recurred 
and  were  afterward  cured  by  the  authors  method,  as  described.  The 
other  fourteen  cases  are  well.  The  vocal  results  in  all  were  very  satis- 
factory, and  especially  so  in  the  cases  with  some  degree  of  arytenoid 
mobility  at  the  start.  Pitch  was  more  or  less  altered,  being  in  most  in- 
stances deeper. 


CHAPTER    XLI. 

Decannulation  After  Cure  of  Laryngeal  Stenosis. 

Abando)intciit  of  the  cannula.  When  a  tracheotomized  case  reaches 
the  stage,  by  whatever  mode  of  treatment,  when  the  patient  is  to  be 
trained  to  breathe  aeain  through  the  mouth,  it  is  necessary  to  occlude 
the  cannula.  The  best  method,  in  our  experience,  is  to  insert  a  rubber 
cork  in  the  inner  cannula.  It  is  quite  unnecessary,  with  a  properly  fitting 
cannula,  to  have  a  fenestrum  in  the  tube.  The  fenestrum  causes  no  end 
of  irritation  and  favors  the  formation  of  granulation  tissue,  because  it  is 
impossible  to  have  the  fenestrum  in  tb.e  lumen  clear  of  contact  with  the 
walls  of  the  trachea.  It  is,  anyway,  unnecessary,  because  plenty  of  air 
will  pass  the  cannula  if  it  be  of  the  projicr  size,  and  breathing  can  be 
unimpeded  without  a  fenestrum.  If  an  attem]it  is  made  to  leave  the 
cannula  out,  no  matter  how  well  the  i)atient  may  be  able  to  breathe, 
there  is  apt  to  be  panic,  because  the  removal  of  the  tube  is  associated 
with  dyspnea  in  the  earlier  history  of  the  case  ;  and  associated  ideas, 
terror  and  nerve  habit  cause  the  panic.  On  the  other  hand,  when  a 
cork  is  used  for  two  or  three  weeks,  the  patient  becomes  accustomed  to 
breathing  through  the  mouth  and  realizes  that  he  can  do  so.  When  this 
confidence  is  accjuired  there  will  be  no  panic.  In  cases  that  cannot  get 
sufficient  air  through  the  mouth,  a  slot  may  be  made  in  the  cork  for  air 
leakage  as  shown  in  Fig.  481.  All  decannulation  cases  must  be  closely 
watched  at  night.  .\  patient  will  Ijc  quite  dyspneic  with  a  cork  thai 
can  be  comfortably  worn  in  day  time.  In  most  instances  where  laryn- 
gostomy  has  not  been  done  the  fistula  into  the  trachea  will  close  very 
rapidly.  'I'his  should  be  retarded  all  tliat  is  jiossible,  and  the  wound 
should  be  packed  firmly  open  until  the  tracheal  cartilage  has  united  com- 
I)letelv.  Otherwi.se,  there  will  be  a  mass  of  granulation  tissue  projecting 
into  the  trachea  at  the  site  of  the  unhealed  wotnid.  In  an  acute  case 
where  a  tracheotoinv  ha-  been  done  for  temi>orary  .stenosis,  if  the  wound 


640        DKCANNULATION  AFTER  CURE  OF  CHROXIC  LARYNGEAL  STENOSIS. 

is  allowed  to  heal  promptly  the  cartilage  will  heal  very,  very  slowly 
and  all  the  time  v.ili  be  throwing  granulations  into  the  trachea,  as  the 
author  had  abundant  opportunity  to  observe  with  the  bronchoscope  some 
years  ago.  (Bib.  SiU)).  These  may  become  so  large  as  to  demand  a  sec- 
ond tracheotomy.  Of  course,  the  granulations  can  be  removed  broncho- 
scopically  and  resorcin  or  other  applications  thus  made,  but  as  a  rule 
it  is  better  in  such  a  case  to  open  the  tracheal  wound  again  and  deal  with 


Fig.  4S4. — Enlarged  illustration  of  cork  used  to  occlude  the  cannula  in  train- 
ing patients  to  breathe  through  the  mouth  again,  before  decannulation.  The  groove 
allows  air  leakage,  the  amount  of  which  is  regulated  by  the  use  of  different  corks 
having  various  sizes  of  grooves  as  indicated  by  the  dotted  lines.  A  smaller  and 
still  smaller  air  leak  is  permitted  until  finally  an  ungrooved  cork  is  tolerated. 

it  properly  by  getting  healing  of  the  cartilage  first.  In  cases  in  which  the 
cannula  has  been  worn  a  great  kngtlt  of  time  the  cartilage  is,  usually, 
covered  with  fibrous  tissue  and  possibly  some  extension  of  the  tracheal 
epithelium,  but  not  enough  to  prevent  a  prompt  union.  It  usually  takes 
but  a  short  period  of  packing  until  the  tracheal  wound  is  united,  and 
the  wound  will  begin  to  fill  up  from  the  bottom,  when  the  packing  will  be 
gradually,  of  necessity,  less  and  less  deep,  until  none  can  be  inserted. 


CHAPTER     XLII. 

Malignant  Disease  of  the  Larynx. 

A  therapeutic  cure  for  cancer  remains  to-day,  as  it  always  has  been, 
a  hope  long  deferred.  As  applied  to  the  larj'nx,  there  has,  as  yet,  been 
no  result  from  the  roentgen  ray,  radium,  mesothorium,  or  other  radio- 
active substances,  vaccines,  diathermy,  foetal  autolytic  products,  or  ionic 
surgery,  that  renders  their  use  advisable  instead  of  operation  in  an  oper- 
able case ;  but  as  post-operative  measures  to  lessen  recurrence  and  for 
palliation,  some  of  these  measures  seem  to  have  value.  Well  planned, 
careful,  external  operation  followed  by  painstaking  after-care,  is  the  only 
cure  so  far  known  and  it  is  a  cure  only  in  a  properly  selected  case.  Endo- 
laryngeal  operation  (  q.  v.j  is  contraiiidicated  except  in  minute  growths 
limitccl  1(1  the  tip  of  the  epiglottis,  which  are  not  strictly  endolaryngeal. 

I'ropliylactic  treatment.  Whether  we  regard  the  influence  of  irrita- 
tion as  a  factor  or  not,  and  whether  or  not  we  regard  the  continuance  of 
chronic  inflammatory  processes  as  resulting  in  segregation  of  ephethelium 
with  subsequent  proliferation  as  a  factor  in  the  etiology  of  cancer,  there 
can  be  no  question  in  the  mind  of  any  one  who  will  review  all  the  evi- 
dence, that  there  is,  in  many  parts  of  the  body,  a  certain  precancerous 
condition  at  the  site  of  cancer.  The  author's  case  records  afford 
abundant  evidence  that  it  is  exceedingly  rare  for  cancer  to  develop  in  a 
previously  normal  larynx.  The  history  of  almost  every  cancer  case  in- 
dicates more  or  less  annoyance  referable  to  the  larynx  for  so  long  a 
period  of  time  that  we  cannot  ignore  the  influence  of  chronic  laryngitis 
as  at  least  a  oredisposing  cause  of  cancer  of  the  larynx.  Specific  ulcera- 
tions and  benign  growths  can  prejiare  a  soil  more  favorable  than  normal 
tissues  for  the  invasion  of  cancer,  and  a  rajiid  cure  of  any  form  of  cur- 
able laryngeal  disease  is  a  i)ro])hylactic  measure. 

Palliative  treatment.  The  four  conditions  that  we  must  combat  with 
palliative  treatment,  are:        (1)     Odor.      (2)      I'ain.     (:!)     Dysphagia. 


C48  MALIGNANT  nsKASi:  OF  THE  LARYNX. 

(4)  Dyspnea.  Odor  is  due  largely  to  the  saprophytes.  To  hold  these 
in  check,  the  local  use  of  antiseptics  and,  above  all,  the  removal  of  secre- 
tions before  there  is  time  for  decomposition,  are  necessary.  Hydrogen 
peroxid  to  remove  secretions,  anrl  dilute  alcohol  as  an  antiseptic,  are 
among  the  very  best  for  these  [uirposes.  Pain  may  be,  to  some  extent, 
controlled  by  insufflation  of  orthoform  and  menthol.  In  dysphagia,  in- 
tubation of  the  esophagus  will  postpone  gastrostomy  until  near  the  end. 
When  gastrostomy  is  indicated,  however,  it  should  be  done  at  once  and 
not  delayed  until  the  patient  has  become  moribund  from  starvation.  For 
odynphagia  when  due  to  ulceration  of  the  epiglottis,  the  author's  experi- 
ence coincides  with  that  of  Sir  St.  Clair  Thomson,  in  the  relief  afforded 
by  the  amputation  of  the  projecting  portion  of  this  structure.  Amputa- 
tion is  a  relatively  minor  procedure.  For  dyspnea,  tracheotomy  should 
be  done  early  before  the  patient's  general  condition  sufifers.  It  should 
always  be  done  low  in  the  neck,  tlse  it  will  soon  be  invaded  by  the  can- 
cerous process. 


CHAPTER     XLIII. 

Malignant  Disease  of  the  Larynx. — Continued. 

CURATIVE  OPERATIONS. 

Contraindtcations  to  attempted  cure  by  operation.  The  contraindi- 
cations to  an}-  operation  other  than  palhative  are :  metastatic  foci,  or- 
ganic disease,  feebleness,  alcohoUsm,  pyorrhea  alveolaris,  suppurative 
disease  of  the  accessory  sinuses.  A  very  high  grade  of  malignancy  is  an 
absohite  contraindication  to  any  operation  other  than  palliative.  This 
seems  to  be  the  contraindication  least  often  recognized.  When  the  rela- 
tively rapid  increase  of  the  growth  in  size,  or  the  laboratory  findings, 
indicate  a  high  degree  of  malignancy,  or  a  very  vulnerable  soil  (which  is 
probably  the  same  thing)  no  operation  whatever  other  than  jialliative  is 
jjermissible,  because  recurrence  is  certain.  Impossibility  of  entire  re- 
moval here,  as  elsewhere,  is  an  absolute  contraindication.  Impossibility 
of  removal  en  masse  of  the  cancerous  tissue,  involving  the  necessity  of 
incision  through  cancerous  tissue  or  infected  lymph  channels,  is  an  abso- 
lute contraindication  iflen  ignored.  It  is  useless  to  remove  infected  nodes 
and  leave  behind  the  channels  by  which  the  infection  was  carried  from 
the  original  focus  to  the  nodes.  Not  only  will  infection  spread  from 
the  unremoved  channels,  but  the  cutting  through  them  will  scatter  the 
infection  which  will  be  taken  up  by  the  open  mouths  of  both  lymph  and 
blood  vessels.  Careful  esophagoscopy  will  often  reveal  infiltration  of  the 
periesophageal  glands,  and  when  this  condition  is  present,  operation  is 
absolutely  contraindicated,  even  if  the  glands  are  cervical.  Within 
the  past  year,  the  author  has  seen  eighteen  cases  of  malignant  disease 
of  the  JarjMi.x,  in  only  one  of  which  did  he  think  operation  advisable.  Of 
the  seventeen  cases  in  which  he  advised  against  any  operation  other  than 
jiaHiative.  five  cases  were  laryngectomized  by  otlier  surgeons  and  all  five 
are  now  dead.  The  contraindications  to  oi)eration  in  e\ery  one  of  these 
cases  was  extension  of  the  disease  to  the  lower  deep  cervical  and  medias- 


G50  MALIGNANT  DISEASE  OF  THE  LARYNX, 

tinal  glands,  and  in  four  of  the  cases  it  was  the  bronchoscope  and  the 
esophagoscope  that  served  to  point  out  the  probability  of  deep  medias- 
tinal glandular  involvements  and  disease  of  the  party  wall  below  the 
larynx.  One  of  the  cases  showed  a  very  high  degree  of  malignancy, 
the  growth  quite  evidently  having  extended  from  the  larynx  downward 
and  involving  the  trachea  and  parly  wall  in  a  period  of  about  four  or  five 
months.  In  such  a  case  recurrence  is  certain,  no  matter  how  radical 
the  removal,  and  any  operation  is  inadvisable  ;  but  this  patient  found  a 
surgeon  who  would  operate.  The  wound  never  completely  healed, 
malignancy  being  found  in  the  granulations  and  rapid  extensions  soon 
terminated  the  case.  Any  operation  other  than  palliative  is  absolutely 
contraindicated  when  there  is  involvement  of  the  party  wall  below  the 
second  ring  of  the  trachea.  This  is  not  because  the  second  ring  of  the 
trachea  cannot  be  removed,  but  simply  because  the  bronchoscope  and 
esophagoscope  in  our  clinic  have  shown  that  when  any  malignant  growth 
has  gone  below  the  second  ring  of  the  trachea,  there  is  involvement  of 
the  mediastinal  lymphatics.  There  is  only  one  way  in  which  to  select 
the  cases  suitable  for  operation,  and  that  seems  exceedingly  difficult  to 
do,  for  most  men.  If  every  one  were  to  approach  every  problem  of 
operability  with  these  two  things  in  mind;  namely,  (a)  mortality,  (b) 
recurrence,  the  general  average  of  the  published  statistics  would  be 
vastly  better.  The  tendency  is  to  go  on  the  principle  of  "We  will  give 
him  a  chance,  anyway." 

Choice  of  operution.  In  an  early  intrinsic  malignancy  of  very 
limited  extent,  not  involving  the  posterior  portion  of  the  larynx,  the  re- 
sults of  thyrotomy  Iiave  been  positively  brilliant.  Nowhere  in  the  whole 
realm  of  the  surgery  of  malignant  diseases  have  such  results  been  ob- 
tained as  in  thyrotomy  in  such  cases.  But  unfortunately,  thyrotomy 
is  being  done  on  cases  in  which  it  is  doubtful  if  even  laryngectomy  could 
save  the  patient's  life.  Cases  have  come  under  our  observation  where 
we  advised  against  thyrotomy,  but  the  patients  afterward  were  thyrot- 
omized  by  other  surgeons,  and  in  every  single  instance  the  disease  re- 
curred. In  two  of  the  cases,  laryngectomy  was  afterwards  done,  follow- 
ed by  a  second  recurrence  and  fatal  termination,  one  case  within  twelve 
months,  and  the  other  fourteen  months  from  the  time  of  the  original 
thyrotomy.  The  author  hopes  that  he  will  not  be  considered  egotistical 
in  making  these  statements.  He  claims  no  originality  whatever  in  the 
matter;  simply  having  followed  the  initiative  of  Sir  Felix  Semon  and 
Sir  Henry  Butlin,  wlio,  seconded  by  Sir  St.  Clair  Thomson,  Mr.  Tilley. 
Dundas  Grant,  Richard  Lake,  Prof.  Moure  and  others,  have  very  clearly 
defined  the  limits  of  operability  and  have  conclusively  proven  that  it  is 


MALIGNANT  DISEASE  OF  THE  LARYNX.  C>')\ 

only  in  intrinsic  malignancy  of  very  limited  extent  that  good  results  can 
be  expected  of  thyrot(jmy.  Notwithstanding  this,  thyrotomies  are  to-day 
being  done  upon  patients  in  whom  there  is  very  extensive  disease,  which 
has  gone  beyond  the  limits  not  only  of  the  intrinsic  area,  but  of  the  en- 
tire larynx.  If  operators  wisii  to  operate  upon  such  cases,  they  at  least 
should  not  report  them  as  thyrotomies  and  befog  the  issue  and  mar 
statistics  by  operations  upon  unsuitable  cases.  The  author  hopes  that  he 
will  be  pardoned  for  speaking  thus  plainly  aliout  these  matters,  but  he 
feels  very  strongly  upon  the  subject,  for  the  reason  that  his  own  work 
has  convinced  him  of  the  beautiful  results  obtainable  by  thyrotomy  in  a 
properly  selected  case. 

It  is  frequently  stated  that  the  larynx  is  poorly  supplied  with  lym- 
phatics, and  this  is  given  as  the  reason  for  the  good  results  obtainable  by 
thyrotomy  in  properly  selected  cases.  This  is  an  error.  The  larynx  is 
very  abundantly  supplied  with  lymphatics  and  they  anastomose  with  each 
other  very  freely,  but  instead  of  leading  out  by  many  channels  they 
empty  into  two  small  glands  on  each  side  without  any  anastomosis  with 
neighbiiriiig  lymphatic  systems  (Cuneo).  To  this  peculiar  lymphatic  ar- 
rangement is  due  the  success  of  thyrotomv  in  the  hands  of  the  few 
operators  who  have  limited  its  use  strictly  to  a  properly  selected  case  and 
who  ha\e  had  the  most  brilliant  results  in  the  surgical  treatment  of 
malignancy  in  any  part  of  the  body.  The  statement  sometimes  made 
that  cancer  will  not  invade  hyaline  cartilage  and  that  this  is  the  reason 
for  favorable  results  in  early  and  radical  laryngeal  operations,  is  an  error. 
Malignant  epithelial  proliferation  will  not  primarily  invade  cartilage; 
but  when  cancerous  processes  proceed  to  ulceration  with  consequent  sec- 
ondary mixed  [lyogenic  infections,  the  cancerous  processes  will  follow 
the  suii]iurati\e  processes  through  the  damaged  cartilage.  Thus  we  not 
infreipicntly  see  cancer,  in  its  later  stages,  perforate  the  thyroid  cartilage. 
I'he  real  reason  for  the  success  of  early  operation  in  laryngeal  malig- 
nancy is  that,  liecar.se  of  the  peculiar  lymphatic  arrangement  mentioned 
above,  the  anteriorly  located,  intrinsic  cancerous  process  does  not,  for  a 
long  time  after  its  incijiiency.  reach  the  cartilage.  .Another  phase  of  the 
subject,  lost  sight  of  by  those  wlio  state  that  hyaline  cartilage  is  not  in- 
vaded by  cancer,  is  that  sarcoma  is  a  form  of  malignancy  that  occurs  in 
the  larynx  and  it  may  invade  the  cartilage  early.  In  one  case  seen  by 
the  author  the  origin  was  in  the  perichondrium  and  the  cartilage  was 
probably  involved  almost  from  the  incipiency.  In  another  case  a  laryn- 
geal endothelioma  had  its  origin  apparently  from  the  perichondrium, 
with  early  cartilaginous  involvement. 

Indicationx  for  tliyratoiny.  Thyrotomy  is  indicated  in  any  instance 
in   which   the   involvement  is   intrinsic   and   is   so   slight   that   there   is   a 


652  MALIGNANT  DISEASE  OF  THE  LARYNX. 

practical  certainty  that  all  of  the  growth  may  be  removed  by  cutting 
through  normal  tissue  and  not  through  neoplastic  tissue.  In  other  words, 
the  cancer  must  not  only  be  intrinsic,  but  it  must  be  of  very  limited  ex- 
tent. If  it  be  quite  extensi\e,  even  though  still  intrinsic,  it  is  reason- 
ably certain  that  at  thyrotomy  all  of  the  tissue  cannot  be  removed. 
Fixation  of  the  cricoarytenoid  joint  renders  party  wall  invasion  probable 
and  if  long  continued  a  recurrence  will  probably  follow  operation. 

Indications  for  laryngectomy.  Laryngectomy  is  indicated  in  any 
operable  case  of  intrinsic  cancer  of  too  great  an  extent  to  be  dealt  with 
by  thyrotomy  without  cutting  into  neoplastic  tissue.  Laryngectomy  is 
indicated  in  laryngeal  cancer  extrinsic  by  origin  or  extension,  if  there  is 
little  or  no  adenopathy,  provided  there  are  no  contraindications  (q.  v.). 

H cmilaryngcctomy.  As  stated  some  years  ago,  the  author  rarely 
advises  the  operation  of  hemilaryngectomy,  because  of  the  much  greater 
infective  risk  as  compared  with  total  laryngectomy.  In  such  cases  as 
are  deemed  operable,  and  in  which  the  disease  cannot  be  completely  re- 
moved by  thyrotomy,  it  has  seemed  better  to  do  a  total  operation,  which 
is  safer  because  the  trachea  is  entirely  cut  off  and  brought  forward 
through  the  skin,  so  that  infection  cannot  set  up  septic  bronchitis. 

Hemicricoarytenoidcctomy  has.  in  our  hands,  been  followed  by  recur- 
rence requiring  the  total  operation. 

Subhyoid  pharynyotomy  was  formerly  a  very  useful  method  of  gain- 
ing access  to  the  upper  orifice  of  the  larynx.  It  has  been  entirely  sup- 
l)lanted  for  all  benign  conditions  by  direct  endoscopic  methods.  For 
malignancy  it  seems  rarely  justifiable  because  of  prompt  recurrence  after 
remo\al  in  this  region. 

MORTALITY    AM)    RESULTS    OF    OPERATION. 

Three  things  have,  in  the  past,  rendered  records  worthless  and  have 
very  much  befogged  the  statistics  of  the  mortality  and  of  the  end-results 
of  radical  operation  for  cancer  of  the  larynx. 

L  The  operation  of  thyrotomy  has  been  confused  with  the  opera- 
tion of  laryngectomy. 

2.  Nearly  all  of  the  cases  operated  upon  for  thyrotomy  were  not 
suitable  cases  for  this  operation.  In  fact  very  few  were  operable  at  all 
by  any  method. 

3.  The  difficulty  not  on\\  in  discovering  the  disease  early,  but  of 
getting  the  opportunity  to  o[)erate  early.  Both  of  these  difficulties  are 
less  than  in  the  author's  early  days.  Then  patients  did  not  so  frequently 
consult  the  laryngologist  for  seemingly  minor  ailments ;  then,  also,  when 
malignancy  was   discovered   early,   the   patient   started   on   a   search   for 


MAI.ICN'AXT  rUSKASE  OF  TIIK   I.ARYXX.  G53 

some  one  who  would  tell  him  he  had  no  cancer.  Such  were  almost  al- 
ways found  in  those  days  and  the  patient's  only  opportunity  for  cure 
was  lost  by  delay. 

One  thing  stands  out  clearl_\-  in  the  results  of  to-day  as  compared  to 
those  of  many  years  ago:  namely,  the  relatively  slight  operative  mortality 
of  total  laryngectomy.  When  the  author  took  up  the  surgical  treatment 
of  laryngeal  malignancy,  laryngectomy  was  still  under  the  blight  of  the 
pre-aseptic  days.  Even  after  the  general  establishment  of  surgical  asepsis 
in  practically  all  other  fields  of  general  surgerj-,  aseptic  technic,  especially 
in  the  dressings,  was  neglected  because  of  the  impossibility  of  absolute 
sterilization  of  the  field  and  prevention  of  its  subsequent  contamination. 
To-day  the  average  operative  mortality  in  the  large  clinics  is  about  ten 
per  cent  and  this  can  be  greatly  reduced  by  refusal  to  operate  except  upon 
the  most  favorable  cases.  Though  largely  freed  of  its  operative  risk. 
lar_\ngectomy  cannot  be  said  to  be  frec|uently  curative  of  cancer,  and  is 
rareh-  advisable.  As  pointed  out  by  Delaxan  (liib.  IKi  and  llS)  the 
exact  curative  value  of  total  larvngectomy  has  not  yet  been  determined 
statistically  because  the  literature  is  entirely  made  up  of  glittering  gen- 
eralities, incomplete  statistics  and  cases  reported  too  soon  after  opera- 
tion. 

Causes  of  death,  in  laryiu/ectoiiiy.  The  operation  of  laryngectomy 
is  necessarily  associated-  with  a  certain  degree  of  shock.  Therefore,  or- 
ganic disease  or  lowered  vitality  of  the  patient,  necessarily  assumes  first 
])osition  as  a  factor  in  mortality.  Injury  to  parathyroids  has  undoubt- 
edly been  a  factor  in  some  instances,  and  injiu-}'  to  both  vagi  doubtless 
has  occurred.  Infection  of  one  vagus  leading  to  an  acute  infective 
vagitis,  may  jiroduce  marked  symptoms  of  depression,  and  may  even 
prove  fatal.  Sloughing  of  the  esophagus  and  other  infective  conditioiis, 
together  with  all  forms  of  sepsis,  and  especially  septic  mediastinitis  liave 
been  reported  by  a  number  of  operators  as  causes  of  death  in  laryngec- 
tomy. 

Excessive  traction  upon  the  esophagus,  as  demonstrated  by  sphyg- 
momanomelric  tracings  (l'"ig.  485)  made  upon  some  of  the  author's  cases 
by  Dr.  Iloyce  (Tiib.  254)  introduces  a  serious  factor  through  cardiac 
inhiliition  as  will  be  understood  from  the  following  notes  of  Dr.  Boyce : 

■'In  regard  to  your  last  thyrotomy  (for  epithelioma  of  the  larynx) 
in  which  I  took  sphyi?:momanonietric  readings,  they  never  fell  below  what 
I  take  to  be  the  patient's  ordinary  tension,  lie  was  at  no  time  deeply 
anesthetized,  and  frequently  struggled.  The  high  readings  1  attribute 
rather  to  muscular  etfort  than  to  operative  irritation.  In  regard  to  the 
two  laryngectomies  of  \ours  in  o.hich   I  took  siihygmomanometric  read- 


634 


MALIGNANT  DISEASE  OF  THE  LARYNX. 


ings,  I  may  say  that  the  most  interesting  feature  of  the  blood-pressure 
chart  in  the  case  of  Mr.  P.  was  the  fall  that  occurred  when  the  larynx 
was  turned  upward.  A  subsequent  fall  occurred  when  the  upper 
end  of  the  esophagus  was  drawn  on  just  previous  to  incising  it.  In  the 
subsequent  case  of  laryngectomy,  that  of  Mr.  ^L,  the  blood  pressure  was 
seen  to  fall  steadily  as  long  as  the  esophagus  was  being  manipulated.  In 
this  latter  case  the  fall  went  almost  to  the  danger  point  I  had  fi.xed  on 
in  my  mind  as  the  one  at  which  the  operation  should  be  stopped.  This 
fall  of  pressure  is  so  remarkable,  and  so  out  of  proportion  to  the  appar- 
ent severity  of  the  operation,   that  it  suggests  the  theory   that   the   de- 


Chan  af  jphygiiomanomftrif  RMrfirgf;  *  -ing  La^rgectOTiy  f'*' 

Fig.   485.— Chart   of    sphymomanometric    readings    recorded   by    Dr.   John    W 
Boycc  dnring  laryngectomy  by  the  author. 

pressor  nerve  mechanism  of  the  human  heart  runs  in  the  substance  of  the 
esophagus.  If  so,  it  might  account  not  only  for  death  on  the  table,  said 
to  occur  in  these  operations,  but  also,  by  the  profound  prostration  in- 
duced, for  some  of  the  inhalation  pneumonias  that  are  reported  as  fol- 
lowing. Whether  other  observation  shall  confirm  this  theory  or  not. 
the  practical  efYect  indicates  most  extreme  caution  in  making  traction 
on  the  esophagus,  and  that  incisions  into  it  should  be  made  with  the  part 
as  nearly  as  possible  in  its  natural  position." 

The  author  has  had  only  two  deaths  from  any  cause  whatever  with- 
in a  month  after  the  operation  of  laryngectomy.  One  of  these  was 
due  to  sloughing  of  the  esophagus,  and  the  other  to  exhaustion  produced 
by  a  severe  therapeutic  test,  in  which  enormous  doses  of  potassium  iodid 


MALIGNANT  DISEASI-  OI-  TIIR  LARYNX.  ()■'>') 

and  mcrcun-  had  %ured.  Since  this  instance,  it  has  been  the  author's 
practice  invariably  to  insist  upon  full  recuperation  after  all  therapeutic 
tests,  before  undertaking  operation. 

Recurrence.  The  deficiency  of  the  lymphatic  drainage  from  tlie 
laryn.K  renders  extension  exceedingly  slow,  so  that  laryngeal  cancer  is, 
in  its  early  stages,  a  purely  local  process,  and  as  such  is  curable  by 
sufficiently  wide  removal.  Recurrence  within  a  year  after  operation  may 
mean  that  the  operat;ve  removal  was  inadequate,  but  it  seems  quite  cer- 
tain that  in  some  instances,  at  least,  it  may  be  due  to  infection  at  the 
time  of  operation  owing  to  cutting  through  malignant  tissue,  as  evi- 
denced by  a  point  of  recurrence  in  the  midst  of  cicatricial  tissue.  Recur- 
rences either  at  the  original  site,  or  in  remote  locations  after  a  period  of  a 
year,  may  be  looked  upon  as  reinfections  on  a  vulnerable  soil.  In  one 
previously  reported  case  of  the  author,  a  patient  died  of  cancer  of  the 
stomach  seven  years  after  larj'ngectomic  removal  of  a  cancer  from  the 
larynx.  This  well  known  case  is  everywhere  regarded  as  reinfection 
upon  a  vulnerable  soil  rather  than  repuUation  of  the  primary  process. 
Had  it  recurred  in  the  neck  in  the  region  from  which  the  larynx  had 
been  removed,  it  would  have  been  regarded  as  a  recurrence.  (See  com- 
ment of  Sir  Felix  Semon,  T'.ib.  -!!>4.)  It  seems  that,  for  the  practical 
determination  of  the  adequacy  of  an  operation,  we  may  sa)-  that  freedom 
from  recurrence  for  a  period  of  one  year  after  operation  indicates  ade- 
quate removal  though  not  necessarily  a  cure.  Everything  in  the  clinical 
history  of  cancer  indicates  that  it  requires  a  vulnerable  soil.  We  cannot 
cure  vulnerability  of  soil  by  operation  nor  by  any  other  known  means. 

For  statistics  and  valuable  data  proving  the  remarkable  curative  ef- 
ficiency of  thyrotomy  the  reader  is  referred  to  the  liibliography  for  ref- 
erences to  various  articles  by  Sir  Felix  Semon,  to  whom  the  world  is 
indeltted  for  the  discovery  of  a  cure  for  that  dreadful  aflliction,  malig- 
nant disease  of  the  larynx.  Convincing  data  will  also  be  found  in  tlie 
writings  of  Sir  Henry  i'.utlin  (llib.  i '>■'<) .  Sir  St.  Clair  TlKinison  (I'.ib. 
53S),  Mr.  Tilley,  Dundas  C.rant,  Richard  Lake,  Mr.  ikirwell.  .Xdam 
Brown  Kelly,  Logan  Turner.  E.  j.  Moure,  Watson  Williams.  Dan  .\lc- 
Kenzie,  Sir  W.  Milligan,  William  Hill,  Stuart-I.ow,  jobscm  llorne.  Hun- 
ter Tod.  Douglas  Harmer  and  others. 

Statistics.  In  publishing,  herewith,  statistics  of  every  case  he  has 
ever  radically  operated  ujion,  the  author  acknowledges  that  he  has  al- 
ways refused  to  operate  on  any  but  the  most  hopeful  cases,  and  the  re- 
sults are  not  claimed  to  be  due  to  any  superiority  of  organization  or  of 
technic,  but  just  simj'ly  to  llie  firm  resolution  to  say  "No"  in  any  but 
the  most  hopeful  cases.  This  has  been  done  with  the  object  of  determin- 
ing what  may  be  accomplished  by  the  operation     of     thyrotomy     when 


656  MALIGNANT  DISKASi;  OF  THE  LARYNX. 

Strictly  limited  to  properly  selected  cases.  Of  the  211  cases  of  malignancy 
in  the  larynx,  four  were  sarcomata,  one  was  an  endothelioma,  and  the 
balance  were  all  carcinomata.  In  eight  instances,  the  malignancy  was 
concurrent  with  lues,  in  three  with  tuberculosis ;  and  in  two  instances 
tuberculosis,  lues  and  carcinoma  all  were  present  in  the  form  of  a  mixed 
lesion  (  iiili.  2.");!).  Since  thyrotomy  is  such  an  ideal  operation  for  in- 
trinsic malignancy,  it  may  be  wondered  why  out  of  118  apparently  in- 
trinsic cases  only  "^V  were  thyrotomized.  The  cases  not  th^rotomized 
were  in  five  classes.  1.  Cases  seen  in  consultation  with  other  operators 
who  themselves  did  the  operation.  '2.  Cases  in  which  the  patient  re- 
fused operation.  3.  Cases  in  which,  though  the  growth  still  remained 
intrinsic,  it  was  of  too  great  an  extent.  4.  Cases  in  which  organic  dis- 
ease elsewhere  contraindicated  operation.  '>.  Cases  in  which  at  thyro- 
tomy the  disease  was  found  to  have  gone  down  the  party  wall,  or  else- 
where invaded  the  tissues  of  the  neck  to  such  an  extent  that  a  more 
radical  operation  than  thyrotomy  was  indicated.  In  our  later  cases, 
such  discoveries  at  thyrotomy  have  not  been  made  because  bronchoscopy, 
esophagoscopy  and  direct  laryngoscopy  have  enabled  us  to  exclude  in- 
volvements lower  down,  such  as  subglottic  infiltrations,  and  particularly 
involvement  of  the  party  wall  not  visible  by  ordinary  indirect  examina- 
tion. In  May,  1909,  in  a  paper  read,  by  invitation  before  the  Xew  York 
Academy  of  IMedicine  (Bib.  250),  the  author  reported  the  statistics  of 
all  the  malignant  laryngeal  cases  in  his  clinic  to  that  date.  The  cases 
seen  since  are  incorporated  with  that  report  in  the  following  complete 
record  of  all  cases  seen  by  the  author: 

Of  ]  I  laryngectomies,  two  died  within  thirty  days,  giving  a  14  per 
cent  operative  mortality.  Four  died  within  a  year  of  local  recurrence, 
three  lived  one  year  and  were  thereafter  lost  to  observation,  two  lived 
two  years,  dying  of  recurrence,  one  two  and  one-half  years,  dying  of 
recurrence,  one  three  years,  dying  of  cerebral  hemorrhage,  one  seven 
years,  dying  of  cancer  of  the  stomach.  Recapitulating  this,  of  fifteen 
complete  laryngectomies,  eight  of  the  patients  were  free  from  recurrence 
at  the  end  of  one  year,  yet  all  arc  dead  now,  and  the  average  duration 
of  life  is  but  little  over  one  year.  These  statistics  were  based  on  a  com- 
plete report  of  all  the  author's  cases  five  years  ago.  and  he  has  not  since 
done  a  total  lar>  ngectomy.  Hy  this  it  is  not  meant  that  such  operations 
are  decn.ied  altogether  unjustifiable,  but  cases  where  he  felt  that  he  could 
honestly  advise  laryngectomy  have  not  since  come  under  the  author's 
care  for  operations,  though  he  lias  seen  two  operable  cases  in  consulta- 
tion that  were  very  successfully  done  by  another  operator,  both  being 
alive  now  at  the  end  of  one  year  and  of  fourteen  months,  respectively. 
Tabular  reports  of  all  cases  in  the  author's  clinic   follow. 


MALIGNANT  DISKASK  OI"    IIIF.  LARYNX.  657 

TABLE  I. 

CANCER  OF  THE   LaRYNX. 

Cases  of  malignant  disease  of  the  larynx  seen  in  27  years,  1886  to  1913 211 

Of  these  the  disease  was  apparently  intrinsic  in I18 

The  disease  was  extrinsic  by  origin  or  extension  in 93 

Of  the  extrinsic  cases  the  growth  had  extended  beyond  the  limits  of  the  larynx 

m .,. 36 

Number  of  patients  operated  upon  (94  operations) 88 

These  operations  were : 

Palliative  tracheotomies,  esophageal  intubations,  etc 36 

Thyrotomies    27 

Complete   laryngectomies    14 

Subhyoid    pharyngotomies    - 9 

Hemicricoarytenoidectomies    2 

Partial  laryngectomies  included  under  laryngectomies   (done  later) 3 

Partial  laryngectomies  included  under  thyrotomies 3 

Of   the  laryngectomies   and   pharyngotomies  there    were    extirpations    of    the 

cervical    esophagus    in 6 

Of  the  laryngectomies  and  pharyngotomies  there  were  extirpations  of  other 
portions  of  neck,  includmg  the  external,  internal  and  common  carotid 
arteries,  pneumogastric  nerve,  jugular  vein,  sulimaxillary  gland,  lymph 
nodes,   tongue,   hypo-pharynx,    etc 8 

TABLE  n. 

Thyrotomy. 

Number   of    operations -7 

Alive  and  well  after  thirteen  years i 

Alive  and  well  after  ten  years i 

Alive  and  well  after  eight    years I 

Alive  an<l  well  after  seven  years 3 

Alive  and  well   after  six  years 3 

Alive  and  well  after  five  years 4 

Alive  and  well  after  four  years - 

Alive  and  well  after  three  years 2 

Alive  and  well  after  one  year i 

Died  of  general  diseases  after  one  year 2 

Lost  trace  of  after  one  year 4 

Died  of  recurrence   (in  spite  of  sul)sequent  laryngectomy) 3 

Died    within    thirty    days o 

Recapitulation:    Of  twenty-seven  thyrotomies,  twenty-four  of  the  patients  were 
free  from  recurrence  at  the  end  of  one  year.     No  operative  mortality. 

It  will  be  noted  in  the  table  that  the  extensive  operations  upon  the 
neck  and  esophagus  and  tissues  adjactnl  to  the  larynx  are  just  the  same 
in  number  in  the  statistics  published  in  1'.)o!».  They  are  included  here 
simply  for  completeness.  The  reason  that  none  of  these  operations  has 
been  done  in  our  clinic  in  the  past  live  years  is  that  in  none  of  the 
cases  that  \vc  have  .ccn  did  conditions  seem  to  justify  such   extensive 


658 


MALIGNANT  DISEASE  OF  THE  LARYNX. 


operation,  for  the  reason  that  in  p/ractically  all  of  them  that  might  have 
been  so  operated,  \vc  have  discovered,  endoscopically,  deep  cervical  or 
mediastinal  lymphatic  extension  which  rendered  operation  unjustifiable. 
Vocal  results  after  operation  for  malignant  disease  of  the  larynx. 
In  all  of  our  cases  of  thyrotomy,  the  patients  have  been  able  to  phonate. 
The  voice  has  been  really  a  good  voice  for  all  practical  purposes.  In 
twentv  of  the  cases,  the  voice  had  a  considerable  degree  of  flexibility. 


Fig.  480. — From  a  photograph  of  a  man  of  fifty-four  years,  taken  six  months 
after  laryngectomy  for  cancer  of  the  larynx.  About  5  cm.  (vertically)  of  the  in- 
volved anterior  esophageal  wall  was  removed,  the  edges  being  stitched  to  the  skin. 
The  upper  aperture  seen  opens  into  the  esophagus;  by  drawing  it  together  with 
the  fingers  swallowing  was  easily  accomplished.  The  lower  opening  is  the  orifice 
of  the  amputated  trachea  which  was  stitched  to  the  skin.  By  placing  a  rubber 
colostomy  pad  over  both  openings  the  tracheal  expiratorj-  blast  went  through  the 
mouth,  giving  the  patient  a  Inud  whispered  voice. 


In  two,  the  voice  was  very  rough  and  lacking  in  flexibility,  though  quite 
loud.  In  four  other  cases,  it  was  necessary  to  damage  the  arytenoid 
joint  in  order  to  make  sure  of  getting  enough  peri-neoplastic  normal 
tissue.  The  voice,  though  useful,  was  not  loud  in  any  of  these  but  was 
more  of  the  nature  of  what  is  commonly  known  as  a  "stage  whisper." 
In  two  of  these  cases,  removal  of  one  arytenoid  was  required  to  get  the 
necessan'  width  of  normal.     In  both  cases  there  was  no  attempt  to  form 


MAI.ICXAXT  I:ISI-;aPK  01'    TlIK  I.ARYW. 


659 


an  adventitious  \c)cal  cord,  corroborating^  the  author's  previously  pub- 
lished original  observation  that  the  traction  by  the  arytenoid  is  the  chief 
factor  in  the  formati-in  of  adventitious  vocal  bands.  In  two  cases  the 
ventricular  bands  phonated  excellently,  there  being  no  tendency  to  the 
generation  of  adventitious  bands  after  removal  of  both  arytenoids.  In 
another  instance  both  ventricular  bands  and  the  normal  and  the 
adventitious  bands,  all  four  vibrated  on  jihonation.  In  the  laryngec- 
tomic  cases,  one   failed   to   develop   a   buccal    voice,   because   he   would 


N 


KiG.  487. — From  a  iiliotojjrapli  of  a  man  of  68  years,  taken  nine  montli.s  after 
laryngectDmy  for  endotliclioma  of  the  larynx.  The  trachea  was  stitched  to  the 
skin  an<l  the  pharyn.x  closed.  (Author's  case.  For  interior  view  of  pharynx  sec 
Fig.  g.   I  Mate   II.) 


not  try  with  sulTicii  nt  patience  and  jiersistence.  in  one,  a  very 
good  useful  voice  resulted  from  the  use  of  a  colostomy  pad,  which 
connected  the  two  oi)enings,  tiie  jiharNngeal  and  the  tracheal,  externally 
on  the  skin  surface    (  I"ig.    ISii)   as  pre\iouslv  reported    (Bib.  354). 

I'ndoubtedly  llie  stitching  of  the  trachea  to  the  skin,  as  first  done 
i)y  Solis  Cohen,  decreases  the  mortalitv  of  laryngectomy ;  but  on  the 
other  hand,  as  pointed  out  by  Sir  St.  Clair  Thomson,  the  patient's  con- 
dition,  should  he   survive,   is  very   much  better  and   more  enjoyable   if 


660  MALIGNANT  DISEASE  OF  THE  LARYNX 

the  Upper  and  lower  air  passages  can  be  connected.  In  Sir  St.  Clair 
Tliumson's  case,  the  patient  used  an  artificial  larynx  for  breathing  and 
speaking,  and  needed  to  remove  the  cork  only  when  unusual  exertion 
called  for  extraordinary  respiration.  In  one  of  our  cases  a  secondary 
operation  to  open  the  pharyn.x  above  the  tracheo-dermal  opening  was 
very  successful  as  to  breathing  and  voice  with  a  prothetic  apparatus,  but 
buccal  and  pharyngeal  secretions  caused  considerable  annoyance. 

Summing  up  the  \  ocal  results  after  external  operation  for  malignant 
disea.se  of  the  larynx,  it  is  well  to  keep  in  mind,  as  mentioned  in 
connection  with  endolaryngeal  evisceration,  the  vocal  results  depend  upon 
the  degree  of  arytenoid  mobility  present  after  operation,  because,  as 
previously  demonstrated  by  the  author,  it  is  the  tugging  of  the  aryte- 
noid that  is  the  chief  factor  in  the  development  of  an  adventitious  cord. 
\\'hile  the  ventricular  bands  may,  and  often  do,  assume  the  function 
of  the  lost  cords,  yet  their  phonatory  result  is  nothing  like  as  good  as  an 
ad\'entitious  cord  with  good  arytenoid  mobility.  Moreover,  the  ventricular 
band  of  one  side  may  require  extirpation  in  the  wide  removal  necessary 
for  the  cure  of  malignancy,  for  under  no  circumstances  should  any  of 
the  foregoing  considerations  of  vocal  results  lead  the  operator  into  the 
error  of  insufficiently  wide  removal.  It  is  well  also  to  remember  that 
at  best  the  buccal  voice  and  the  artificial  larynx  are  incomparable  to  even 
a  whispered  laryngeal  voice,  therefore,  laryngectomy  is  warranted  only 
when  nothing  less  will  offer  good  hope  of  cure.  But,  finally,  no  con- 
sideration of  conservation  of  voice  should  weigh  against  life-saving 
thoroughness  of  extirpation. 


CHAPTER     XLIV. 

Technic  of  Thyrotomy  for  Malignant 
Disease  of  the  Larynx. 

Preparation  of  tin-  palicnt.  <_)rai  sepsis  is  the  greatest  elenient  of 
risk  in  any  laryngeal  operation,  therefore  the  most  important  part  of  the 
preparation  of  the  jiatient  is  to  have  carious  teeth  filled  or  removed  and 
to  have  the  entire  mcjuih  put  in  as  clean  and  as  healthy  a  condition  as 
possihle  by  the  dentist,  and  there  must  be  no  hesitation  in  removing  ques- 
tionable teeth.  Frcf|uent  brushings  of  the  teeth  with  a  good  paste  or 
powder  of  which  chalk  is  the  base,  together  with  frequent  rinsings  with 
alcohol  2.")  per  cent,  which  is  the  best  non-toxic  antiseptic,  should  be  kept 
up  before  as  well  as  after  operation.  The  usual  general  surgical  prepara- 
tions should  be  carried  out  in  every  detail  as  to  bath,  laxative,  fast,  etc. 
The  beard  and  moustache  should  be  renimcd.  if  the  patient  have  these, 
and  the  face  should  be  freshlv  shaven  the  morning  of  the  day  of  opera- 
tion. 

.Incsthcsia.  When  the  autiior  had  developed  a  local  anesthetic 
technic  to  the  |ioint  where  thyrt)tomy  in  any  man  of  normal  courage 
could  be  done  under  hn-al  anesthesia,  he  felt  that  a  very  distinct  advance 
had  been  made  in  his  work,  but  since  operating  upon  the  last  few  ca.ses 
under  intratracheal  insufllation  anesthesia  with  ether,  using  the  Elsberg 
apparatus,  there  seem  to  be  Wxc  great  advantages  in  favor  of  ether, 
when  used  by  insul'llution.  In  the  first  place,  the  return  flow  of  air  and 
ether  \apor  remove  from  the  trachea,  and  keep  out  of  the  lower  air 
passages,  all  blood  and  secretions.  ( ■.'  )  The  cough  reflex  can  be  abolish- 
ed for  a  few  moments  at  a  time,  \\henc\er  desired,  and  as  promptly 
brought  back  b\-  switching  fr(]m  ether  to  jjure  air.  (  :"! )  When  the  insul- 
flation  tube  is  inserted,  there  is  no  more  concern  about  the  anesthetic,  save 
to  ask  the  anesthetist  to  increase  or  lessen  the  depth  of  anesthesia,  as 
desired.     (4)     The  great  saving  of  ojierative  duration  o\  er  lracheotom\ 


663      TKCHNIC  OF  THVROTO.MV  FOR  MALIGNANT  DISEASE  OF  THE  LARYNX. 

which  formerly  was  used  by  some  operators  for  the  dual  purpose 
of  administering  the  anesthetic  and  of  tamponning  the  trachea  with  a 
tampon  cannula,  (."i )  The  anesthetist  is  removed  far  from  the  operator's 
way.  Should  it  later  be  found  necessary  to  abandon  the  thyrotomy 
and  do  a  lar\-ngectomy,  all  that  is  necessary  is  to  incise  the  trachea 
below  the  involvement  and  insert  a  fresh  sterile  insufflation  catheter 
through  the  incision,  the  insuftlation  nozzle  being  transferred  to  the 
new  catheter.  In  doing  the  (iluck  operation  of  laryngectomy  from 
above  downward,  the  catheter  can  be  inserted  into  the  upper  orifice  of  the 
larynx  through  the  upper  part  of  the  skin  incision,  and  the  peroral  tube 
removed.  In  either  case  the  result  is  the  same.  The  anesthetizing  tube 
is  entirely  out  of  the  operator's  way,  and  combined  with  the  Trendellen- 
berg  position,  the  flow  of  blood  is  entirely  upward.  It  cannot  reach  the 
lower  air  passages  because  of  the  return  flow  of  air.  It  is  surprising 
how  little  space  the  insufflation  catheter  occupies  in  the  larynx.  One 
would  have  anticipated  that  it  would  be  considerably  in  the  way  in  the 
operation  of  thyrotomy,  but  on  the  contrary  it  remains  closely  in  the 
posterior  portion  of  the  larynx  (Fig.  488)  and  could  easily  be  moved  a 
little  to  one  side,  if  it  were  necessary  to  excise  any  piart  of  the  posterior 
wall.  As  a  matter  ot  fact,  if  it  is  necessary  to  excise  any  part  of  this 
wall,  the  operation  of  thyrotomy  is  contraindicated  anyway,  for  rea- 
sons already  mentioned.  Another  great  advantage  of  insufflation  anes- 
thesia in  thyrotomy  is  that  the  operative  incision  need  be  only  long  enough 
to  expose  the  thyroid  and  cricoid  cartilages,  consequently,  the  isthmus  of 
the  thyroid  gland  need  not  be  divided,  thus  saving  much  time  in  ar- 
resting oozing,  etc.,  as  compared  to  the  long  incision  required  for  the  in- 
sertion of  a  tracheotomy  tube  for  anesthesia  below  the  thyrotomic  wound. 
In  the  use  of  local  anesthesia  for  thyrotomy,  the  interior  of  the  larynx 
should  be  thoroughly  cocainized  through  the  direct  laryngoscope.  This 
is  done  with  two  pairs  of  operating  gloves,  one  pair  being  removed  after 
the  cocainization  so  as  to  lose  no  time  starting  the  external  operation. 
The  skin  is  now  infiltrated  as  advised  for  tracheotomy  (q.  v.).  If  the 
stages  of  the  operation  are  now  done  with  a  proper  degree  of  facility, 
the  entire  operation  can  be  completed  within  about  ten  minutes,  and  no 
further  anesthesia  will  be  necessary.  If  a  longer  time  is  occupied,  it  will 
be  necessary  to  infiltrate  the  endolarygeal  structures  with  the  previously 
mentioned  infiltration  solution.  The  reason  for  making  the  endolaryn- 
geal  application  is  that  a  nuich  more  profound  effect  can  be  obtained  be- 
fore an  incision  is  made  than  afterward.  It  is  necessary  in  the  endo- 
larvngeal  application,  to  use  a  "■ii»  per  cent  solution  of  cocaine,  and  ad- 
renalin may  be  added  if  desired  in  order  to  intensify  the  effect  of  the 
cocaine,  and  also  to  cause  a  sharp  limitation  of  the  growth,  as  advised 


TKCHNIC  OF  THVROTOMV  I'OU  MALU'.XANT  DISEASE  OF  THE  LARYNX.     Gfi3 

by  Sir  St.  Clair  Thomson,  ll  is  necessary  to  hold  the  solntion  in  con- 
tact for  twenty  or  thirty  seconds;  simply  brushing  is  not  sufficient.  Of 
course  the  patient  must  be  war.ned  that  he  cannot  breathe  during  this 
time,  and  it  is  necessary  to  get  his  confidence  in  order  that  he  will  not 
struggle  or  become  alarmed.  If  it  is  desired  to  administer  chloroform, 
two  methods  are  available.  ( 1  )  The  old  method  with  a  tampon  can- 
nula inserted  through  a  tracheotomic  wound,  as  the  first  step  in  the  opera- 
tion, or  using  an  ordinary  cannula  and  tamponning  the  trachea  after  the 
larynx  is  open,  with  a  gauze  sponge,  to  which  a  silk  cord  is  attached. 
This  is  pushed  down  through  the  laryngeal  opening,  completely  occluding 
the  trachea  above  the  cannula.  The  chloroform  inhalation  tube,  or,  bet- 
ter, the  hand  ball  insuftlation  api)aratus.  may  be  attached  to  the  tracheal 
cannula  for  the  administration  of  chloroform.  (2)  The  other  method 
is  to  have  the  anesthetist  hold  a  sponge  saturated  with  chloroform  over 
the  wound  inlerniittently.  .Veither  of  these  methods  is  in  any  way  com- 
|)arable  to  the  intratracheal  insuftlation  of  ether.  A  general  anesthetic  by 
the  ordinary  ojjen  method  is  dangerous  in  any  case  with  even  the  slight- 
est dyspnea,  but  thyrotomy  is  rarely,  if  ever,  justifiable  in  any  malignant 
case  that  is  so  far  advanced  as  to  produce  the  slightest  evidence  of 
dyspnea. 

To  forestall  excessive  coughing  the  trachea  may  be  punctured  and 
2  cc.  of  a  2  per  cent  cocaine  solution  may  Ijc  injected  into  the  tracheal 
interif)r  with  a  hypodermic  syringe  before  incision. 

Operative  technic  of  tliyrotomy.  The  tecbnic  of  thyrotomy  for 
cancer,  is  quite  simple.  Th.e  insufflation  catheter  being  in  place,  and  the 
patient  anesthetized,  the  operator's  headlamp  in  place,  the  skin  surface 
being  sterilized  by  the  usual  iodine  method,  an  incision  is  made  in  the 
skin  from  the  level  of  the  hyoid  bone  to  about  the  level  of  the  second 
ring  of  the  trachea.  The  long  incision  previously  made  when  a  tracheot- 
omy tul)e  was  to  be  inserted,  is  unnecessary,  but,  of  course,  an  ample 
length  of  incision  is  always  wise  in  any  operation  about  the  neck.  The 
thyroid  and  cricoid  c:.rtilages  are  (piickly  laid  bare  without  elevating  or 
otherwise  damaging  the  outer  iierichondrium.  It  being  necessary  to  re- 
move the  inner  pericl;ondrium.  the  removal  of  any  of  the  outer  perichon- 
drium would  result  in  chondrial  necrosis  with  consequent  laryngeal  sten- 
osis. The  thyroid  cartilage  is  split  up  the  median  line  with  the  turbino- 
tome (Fig.  HIS  ).  In  making  this  d\\>  with  the  turbinotome,  it  is  essential 
in  cases  of  growtlis  that  are  close  to  the  anterior  commissure,  to  make  the 
cut  sufficiently  to  one  side  to  avoid  cutting  tlirough  the  growth,  in  com- 
pliance with  the  well  known  surgical  principle  that  it  is  necessary  to  avoid 
cutting  through  malignant  tissue.     I'or  this  purjiose  it  is  always  necessary 


66-i     TECHNIC  OF  TIIYROTOMV  FOR  MALICNAXT  DISEASK  OF  THE  LARYNX. 

to  have  previously  made  an  accurate  localization  by  laryngoscopy,  direct 
or  indirect.  In  some  instances,  it  may  be  found  necessary  to  split  the 
cricoid  cartilage,  though,  as  a  rule,  this  should  be  avoided.  In  reopera- 
tions the  old  incision  must  be  followed  (See  Fig.  4l)!M.  The  lateral  wings 
of  the  thyroid  cartilage  are  easily  spread  with  retractors,  giving  a  good 
view  of  the  interior  of  the  lar\nx.  The  cricoid  cartilage,  because  it  is  a 


Fin.  488. — Illustration  of  thjrotomy  or  laryngofissure.  A,  shows  the  line  ol 
incision  through  the  thyroid  cartilage.  The  tubinotome  is  inserted  at  the  crico- 
thyroid membrane,  the  points  passing  upward  (Fig.  468).  B,  shows  retractors 
placed  inside  the  larynx  to  hold  back  the  wings  of  the  divided  thyroid  cartilage. 
In  the  median  line  is  seen  the  insufflation  anesthesia  catheter.  The  growth  is  on 
the  left  vocal  cord.  Perichondria!  dissection  begins  at  the  divided  edge  of  the 
thyroid  cartilage,  the  retractor  being  shifted  to  the  bared  cartilage  as  soon  as  suf- 
ficient perichondrium  has  been  separated.  It  will  be  noted  that  the  cords  do  not 
look  like  the  thin  bands  seen  perorally.  They  are  identified  by  their  position  be- 
low the   ventricle. 


complete  ring,  spreads  less  easily  if  partially  ossified,  as  it  often  is  Care 
must  be  taken  not  unnecessarily  to  injure  the  divided  ends  of  any  of  the 
cartilages,  in  using  retractors  or  otherwise. 

The  most  astonishing  thing  to  the  operator  who  opens  the  larynx  for 
the  first  time  is  the  totally  different  appearance  of  the  larynx  as  compared 
to  the  laryngoscopic  image.    He  expects  to  see  two  white  ribbon-like  vocal 


TKCIIMC  OK  TIlVROTdMV  I'OK  M Al.K'.NANT  DISICASK  ni"    Illi:   I.ARYNX.     665 

bands,  and  instead  has  great  difficulty  in  identifying-  anything  resembling 
a  vocal  cord.  The  landmark  for  which  the  operator  must  look  is  the 
ventricle.  The  ridge  bounding  the  ventricle  above  is  the  ventricular  band, 
and  the  ridge  bounding  it  below  is  the  vocal  cord.  This  ridge,  of  broad 
base  and  triangular  cross  section,  has  a  thick  rounded  crest  and  this  crest 
is  the  vocal  cord.     (Fig.  488). 

Observation  of  the  size  and  position  of  the  growth  in  llie  open  larynx 
will  determine  the  plan  of  excision.  The  first  step  will  be  to  plug 
the  pharyngeal  orifice  with  a  tethered  tampon.  In  every  instance,  it 
is  necessary  to  remove  the  inner  perichondrium,  and  the  incisions  of 
the  overlying  soft  parts  must  be  in  the  normal  widely  out  fnim 
the  diseased  area.  The  perichondrium  is  best  raised  with  a  periosteum 
elevator,  such  as  Freer  uses  for  septal  work,  after  a  start  is  made 
with  the  knife.  Toothed  forceps  lacerate  and  do  n(Jt  hold  as  well 
as  the  author's  grasping  forceps.  (Fig.  470).  After  the  removal  of  the 
growth,  close  inspection  of  it  will  determine  whether  or  not  a  sufficiently 
wide  area  of  the  nfirnial  has  been  removed.  If  it  has  not,  it  is  unfortun- 
ate, but  the  best  thing  to  do  is  to  excise  an  additional  jiortion  of  the 
normal,  and  if  it  is  found  that  the  initial  clipping  has  been  done  too  close 
to  the  growth,  it  is  necessary  to  attack  the  opposite  side  of  the  larynx 
and  do  a  perichondria!  dissection  of  a  sufficient  area.  The  reason  for 
pcrichondrial  dissection  is  that  cartilage  and  bone  as  before  stated  are  not 
readily  invoKed,  while  [jcrichondrium  is  in  some  cases  attacked  by  malig- 
nant disease,  and  it  should  be  removed  though  api)arently  normal,  lest  it 
hf.  invaded.  Tf  it  is  found  that  the  cartilage  itself  has  been  invaded  by 
the  mixed  pyogenic  infections,  the  case  is  not  one  for  thyrotomy,  and  the 
entire  larynx  ,'uh1  trachea  should  be  remo\ed,  unless  it  is  found,  on  ex- 
ploration, that  the  dec])  lym])hatics  of  the  neck  are  involved  all  the  way 
down  to  the  level  of  the  clavicle,  in  which  case  it  is  far  better  to  abandon 
the  operatiim  and  insert  a  iracheotomic  cannula  after  remoxing  whatever 
tissue  has  been  detached  in  the  larynx.  The  jjatient  will  live  longer  with 
the  iracheotomic  cannula  In-  way  of  palliation,  than  he  would  if  the  entire 
larynx  were  removed  in  such  a  case,  for  involvement  of  the  deep 
cer\-ical  lymphatics,  as  mentioned,  means  almost  invari.ably  that  the 
mediastinal  lymjjhatics  arc  also  involved,  rendering  comi)lete  extirpation 
impossible.  In  ])ractically  all  instances  that  are  adapted  to  the  opera- 
tion of  thyrotomy,  the  dissection  will  need  to  be  begun  at  the  divided 
edge  of  the  thyroid  cartilage.  The  ideal  operation  is  the  one  in  which 
a  relatively  large  mass  of  normal  tissue  is  removed  with  the  malignant 
growth,  standing  up  as  an  island  in  the  center,  with  an  area  of  at  least 
Ti  mm.  fpreferablv  more)  of  apjiarently  normal  tissue  in  every  direction. 
Should  the  growth  bv  anv  mischance  be  cut  through,  all  instruments  that 


Olilj       TECHNIC  OF  THYROTOMV  FOR  MAI.IGNAXT  DISEASE  OF  THE  LARYNX. 

have  been  used  in  the  cutting  shoulci  not  be  used  again  unless  resterilized 
and  the  growth  should  be  removed  with  the  greatest  possible  rapidity ; 
for  regardless  of  our  theories  as  to  the  infectiousness  of  cancer,  the 
fact  remains  that  there  is  a  sound  basis  for  the  opinion  that  recurrences 
in  the  scar  are  due  to  wound  infection  at  the  time  of  operation,  cjuite 
as  often  as  to  incomplete  removal.  Great  care  should  be  taken  to  avoid 
unnecessary  injury  to  the  cricoarytenoid  joint  because  the  formation  of 
an  adventitious  cord,  as  demonstrated  by  the  author,  depends  largely 
upon  the  traction  of  the  corresponding  arytenoid  to  pull  out  a  new  cord 
from  the  scar  tissue.  Obviously,  this  must  not  be  considered  if  complete 
removal  of  a  sufficiently  wide  area  of  normal  requires  removal  even 
of  the  entire  arytenoid,  I'.leeding  is  carefully  arrested  at  each  step  of 
the  ojieration  so  as  to  keep  the  wound  as  drv  as  possible.  After  the 
excision  of  the  growth  with  its  normal  surrounding  tissue,  there  may  be 
considerable  oozing,  and  in  a  few  instances,  it  may  be  necessary  to  twist 
or  even  tie  vessels.  Ordinarily,  however,  the  bleeding  soon  ceases  under 
pressure  with  gauze  sponges  and  the  exposure  to  the  air.  \\"hen  satisfied 
as  to  completeness  of  removal,  and  all  hemorrhage  having  been  stopped, 
a  stitch  may  be  put  at  the  upper  ends  of  the  skin  incision,  if  the  incision 
has  been  rather  long.  Dr.  Patterson  and  the  author  are  convinced  that 
to  make  any  attempt  to  stitch  together  the  divided  wings  of  the  thyroid 
cartilage,  or  the  perichondrium  covering  the  outside  of  the  thyroid 
cartilage,  is  a  great  mistake.  Every  swallowing  movement,  which  is.  of 
course,  unavoidable,  will  separate  the  cut  edges  of  the  thyroid  cartilage 
so  strongly  that  it  will  tear  out  any  suture  that  can  be  placed,  result- 
ing in  needless  damage  to  the  important  laryngeal  framework.  It  is  far 
better  for  safetv  and  from  every  other  point  of  view  to  pack  the  wound 
widely  open  until  the  cartilages  have  united  by  fibrous  union,  which  they 
will  do  in  exactly  the  right  position  without  any  stitches  whatever,  if 
the  patient  lie  on  his  back  with  his  head  straight  almost  constantly  dur- 
ing the  after-treatment.  The  method  of  dressing  developed  by  Dr.  Pat- 
terson, is  ideal.  (Bib.  20S).  A  large  triple  layer  of  gauze  is  spread 
over  the  wound  and  the  entire  front  of  the  neck.  A  firm  roll  of  gauze 
is  then  forced  down  into  the  wound  pushing  ahead  of  it  the  triple  layer 
of  gauze.  (Fig.  47 fi).  By  this  method  the  wound  is  kept  widely  open, 
and  yet  there  is  no  risk  of  any  ends  of  packing  getting  down  into  the 
trachea  thus  causing  irritating  cough,  or  even  asphyxia.  This  gauze 
should  be  wrung  out  of  bichloride  solution  l:li>,0(M),  and  the  dressing 
should  he  changed  every  three  hours.  Any  tendency  of  the  skin  to  dip 
down  into  the  wound,  must  be  combated  by  elevation  of  the  skin  edges 
at  each  dressing.  When  the  cartilages  have  united  by  good  firm  fibrous 
union,  the   wound   mav  be   allowed   to   close   from   the  bottom.     If   the 


TECHNIC  OF  TIIVKnTOMV  FOR  MALIGNANT  DISEASE  OE  THE  LARYNX.     G67 

larynx  is  closed,  and  the  skin  closed  over  it,  as  advised  by  some  oper- 
ators, not  only  is  there  danger  from  endolaryngeal  swelling  after  pri- 
mary union  of  the  skin;  but,  undrained  externally,  the  cartilage  will 
fungate  as  it  always  does  in  healing,  and  fungations  will  occlude  the  in- 
terior of  the  larynx  and  trachea,  not  only  misleading  the  operator  into 
suspecting  recurrence,  but  the  fungations  may  be  so  exuberant  as  to  oc- 
clude the  larynx  and  require  tracheotomy,  to  say  nothing  of  the  risks  of 
septic  bronchitis  from  the  discharges  thrown  of¥  by  the  granulating  sur 
face  into  the  interior  of  the  air  passages.  Cartilage  is  slow  to  heal  and 
it  is  much  slower  in  the  absence  of  external  drainage. 

After-care  of  thyrotoiuic  cases.  It  is  wise  to  put  elevating  blocks 
under  the  foot  of  the  bed  for  4.S  hours,  and  during  this  time,  the  patient 
should  lie  upon  his  back  with  sand  pillows  on  each  side  of  his  head  in 
order  to  keep  the  head  straight  in  the  median  line  so  that  there  will  be 
no  twist  on  the  laryngeal  cartilages  from  traction  by  the  tissues  of  the 
neck.  After  48  hours,  there  will  be  little  risk  of  permanent  displacement 
of  the  divided  thyroid  cartilage.  Patients  sit  up  in  bed  on  the  third 
day,  and  get  out  and  move  about  on  the  fourth.  It  is  absolutely  necessary 
to  have  an  abundance  of  fresh  air  at  all  times.  The  windows  should  be 
widely  open,  or  better  still,  the  patient  should  be  in  a  fresh-air  room 
It  is  absolutely  necessary  to  have  nurses  skilled  in  tracheal  work  in  order 
that  the  wound  shall  be  dressed  every  third  hour,  and  also  to  meet  any 
emergencies  that  may  arise.  ( )rdinarily,  however,  emergencies  and  com- 
plications are  rare.  If  the  arytenoids  and  s])hincter  are  injured  and 
there  is  no  undue  reaction  and  no  excision  of  any  ]>art  of  the  upper 
oritice  of  the  larynx,  the  patient  will  have  no  difficulty  in  swallowing 
without  leakage.  The  first  test  should  he  made  with  sterile  water,  and 
all  foods  should  be  sterile  liquids  for  a  week,  by  which  time  granulations 
will  protect.*  X'ocal  rest  is  necessary.  It  is,  however,  not  wise  to  keep 
the  patient  silent  too  loni;,  for  some  vocal  eft'orl  will  prewnt  stiffening 
of  the  arytenoid  joints,  and  an  occasional  attempt  to  sjicak  will  do  no 
harm,  jirovided  there  are  long  intervals  of  rest  between.  About  three  or 
four  times  a  day,  the  |iatient  should  ask  for  any  reijuirements.  in  order 
to  give  a  few  moments  use  to  the  laryngeal  motor  mechanism.  After 
healing  of  the  wcnind  the  larynx  should  be  examined  once  a  week  with  the 
mirror.  It  is  usually  best  not  to  remove  any  little  suspicious  fungation 
that  may  ajjpear  after  a  few  weeks.  It  will  he  found  usually  that  what 
appeared  to  be  a  recurrence  is  only  a  fungating  granuloma  that  will  dis- 
appear spontaneously.  Healing  is  usually  complete  in  three  or  four 
weeks. 


•sir  FeUx   .Semon  advises  fi-edins  the  patient   in   the  horizontal   position   on   the 
operated  side,  the  head  hantring  .sllRhtly  over  the  edge  of  the  bed. 


668      TECHNIC  OF  THVROTOMV  FOR  MALIGNANT  DISEASE  OF  THE  LARYNX. 

Modifications  of  the  foregoing  technic.  The  foregoing,  is,  in  brief, 
the  method  of  operation  and  of  after  care  followed  by  Dr.  Patterson  and 
myself.  We  do  not  use  a  curette  because  if  it  remove  any  infected  tis- 
sue, it  will  simply  stir  the  infection  about  and  implant  it  in  the  soil  to 
cause  a  recurrence,  later.  If  it  remove  no  infected  tissue,  it  is  unneces- 
sarv  to  use  it,  and  as  compared  to  a  clean  cut,  it  leaves  a  surface  which 
is  slower  healing.  No  other  plan  than  clean  cutting  is,  in  our  opinion, 
satisfactory.  The  use  of  the  galvano-cautery  knife  for  the  excision  of 
malignancy  elsewhere  has  proven  advantageous ;  and  may,  e\entually 
prove  satisfactory  for  larj'ngeal  malignancy.  ( )perators,  who  prefer 
general  anesthesia  and  are  without  an  intratracheal  insufflation  ether 
apparatus,  do  a  preliminary  tracheotomy  as  low  as  possible  and  insert 
an  ordinary  tracheal  cannula  through  which  the  anesthetic  is  given. 
The  Hahn  and  Trendelenberg  cannulae  are  no  longer  used.  Instead, 
after  the  larynx  is  opened  gauze  packing  is  firmly  placed  down  in  the 
trachea  above  the  cannula  to  prevent  trickling  down  of  blood  antl  secre- 
tions. 

Coniplications.  Necrosis  of  cartilage  with  subsequent  stenosis  may 
result  from  damaging  the  cartilage  of  both  perichondria,  or  from  inser- 
tion of  stitches,  both  of  which  are  avoidable.  In  case  of  reoperations  an 
island  of  cartilage  may  die  if  the  line  of  fibrous  union  of  the  previous 
incision  be  not  followed  as  mentioned  under  '"Laryngostomy"'  (Fig.  -469). 
Lung  complications  after  thyrotomy  by  the  methods  herein  given  are 
exceedinglv  rare. 


CHAPTER     XLV. 

Technic  of  Laryngectomy. 

Preparation  of  the  patient  is  the  same  as  for  thyrotoniy. 

Position  of  the  patient.  As  advised  for  thyrotoniy  the  best  position 
of  the  ])atient  is  a  combined  Trendelenberg-Rose  ])osition.  The  incHna- 
tion  of  the  tal)le  need  not  be  extreme  if  the  intratracheal  insuttiation 
anesthesia  be  used 

Anesthesia.  It  is  quite  feasible  to  remove  the  larynx  with  local 
anesthesia,  by  infiltrating  first  the  skin  and  then  the  deeper  tissues  as 
they  are  approached.  But  much  o[)erative  time  will  be  saved  and  shock 
diminished  by  intratracheal  insuffiation  anesthesia.  It  this  be  not  used, 
the  only  safe  wa\-  of  using  general  anesthesia  without  prolonging  the 
oiieration  is  to  administer  the  anesthetic  through  a  preliminarily  inserted 
tracheal  cannula.  A  gauze  sjionge  is  kept  saturated  continuously  by  very 
small  drops  of  ether  as  advocated  by  Ferguson.  I'nder  no  circumstances 
should  etherization  be  attempted  by  the  ordinary  method  through  the 
mouth  if  there  is  the  slightest  degree  of  dyspnea,  for  reasons  given  in 
Chapter  XXX\'II.  If  the  operation  is  done  by  the  Keen  or  Gluck  meth- 
ods, from  above  downward  without  tracheotomy,  the  insufllation  is  start- 
ed with  the  catheter  inserted  through  the  mouth  in  the  usual  way.  When 
the  stage  is  reached  where  it  is  desired  to  draw  the  laryn.x  forward. 
a  fresh  sterile  insufilation  catheter  can  be  inserted  into  the  upper  orifice 
of  the  larynx  and  the  anesthetic  thus  continued  until  the  trachea  is  ampu- 
tated, when  the  catheter  is  removed  and  a  fresh  one  inserted  into  the  lower 
trachea  after  the  remo\al  of  the  ;im]iutated  larynx. 

Operative  teehnie  of  larynyectomy.  Two  classes  of  procedure  have 
been  followed.  In  one  the  extirpation  of  the  larynx,  without  tracheo- 
ti>ni\'.  begins  aiio\e.  at  the  th\rohyiiid  nieiiibranc,  the  larynx  being  drawn 
forward  as  il  is  separated  from  ilie  jjarty  wall,  and  the  amputation  from 
the  trachea  being  done  when  sufticient  of  the  larynx  and  trachea  have 
been    thus    dissected    loose    and    dr;u\'i    nut.       |)uring    the    operation    the 


670 


TIXHNIC   OF    LAKVNGKCTOMY. 


Fig.  489. — Schematic  illustration  of  laryngectomy  with  the  aid  of  intra- 
tracheal insufflation  anesthesia.  At  i  .is  shown  the  trachea  and  larynx  exposed 
during  anesthesia  administered  with  the  Elsberg  apparatus  through  the  silk-woven 
catheter,  C,  held  in  place  with  the  Janeway  bite  block  D.  The  incision  has  been 
made  of  T-shape,  as  will  be  understood  by  the  sutured  wound  in  4.  The  trachea 
is  elevated  forward  by  means  of  the  grooved  director  inserted  carefully  between 
the  trachea  and  the  esophagus.  Two  anchor  sutures  are  inserted  around  the 
first  ring  of  the  trachea  as  shown  at  A,  B,  after  preliminary  incision  of  the 
intcrannular  membrane. 

2.  The  trachea  has  been  severed  between  the  cricoid  and  the  first  ring, 
drawn  forward,  and  firmly  fastened  with  the  anchor  sutures  (A,  B)  at  S.  A 
fresh  insufflation  catheter  (C)  has  been  inserted  for  the  continuation  of  the 
anesthetic.  The  larynx  has  been  dissected  free  from  the  esophageal  wall  (E) 
and  is  held  forward  with  the  forceps,  F. 

3.  The  scissors  are  shown  dividing  the  cornu  of  the  thyroid  cartilage.  The 
pharyngeal  wall  has  been  divided  so  as  to  free  the  larynx  posteriorly  and  this 
clipping  will  be  continued  around  over  the  front  so  as  to  free  the  entire  larynx, 
by   severing  the  thyrohyoid   membrane. 

4.  The  wound  is  stitched  together  througliout  its  entire  extent  after  sutur- 
ing the  pharynx,  putting  in  supporting  sutures,  and  securely  anchoring  the  tra- 
chea to  the  skin   (Modified   from  Molinie). 


TIXIIMC  OI"   I.ARVXGKCTOMV.  671 

anesllietic,  which  has  heen  started  thrnni^'li  the  nioiUh,  is  given  through 
the  oiitdrawii  larynx.  The  other  method  i.s  used  after  prelinnnary 
tracheotomy.  The  trachea  i.s  dixided  below  the  cricoid  and  the  laryn.x  is 
dissected  away  from  the  party  wall  by  working  upward  from  below.  (Fig. 
489). 

The  author  prefers  to  do  a  preliminary  tracheotomy  about  a  week 
beforehand  so  as  to  permit  firm  adhesions  between  the  trachea  and  the 
soft  tissues  of  the  neck  to  anchor  the  trachea  firmly,  thus  avoiding  the 
tendency  to  retraction  within  the  thorax,  when  the  trachea  is  afterwards 
cut  off  and  stitched  to  the  skin.  The  inflammatory  adhesions  in  the 
neighborhood  of  the  trachea  close  various  avenues  by  which  infection 
could  find  its  way  into  the  mediastinum,  and  this  barrier  can  be  increased 
as  desired  by  a  blunt  dissection  around  the  sides  of  the  trachea.  (3ne 
week  later,  the  trachea  is  amputated  (as  low  as  previous  bronchosco]n- 
has  indicated)  through  a  T-shajied  incision,  the  transverse  portion  of 
which  is  at  about  the  level  of  the  thyroid  notch,  the  vertical  portion  ex- 
tending;- diiwnward  as  far  as  may  be  needed,  liul  preferably  not  into  the 
preliminary  tracheotomy  wound.  The  traclieal  end  of  the  larynx  is 
raised  very  carefully  without  undue  traction  ui)on  the  esophagus,  and  is 
carefully  freed  from  the  esophagus  from  below  upward,  until  the  aryte- 
noids are  reached.  Tiie  vagi  and  the  parathyroids  should  be  carefully 
avoided,  especi;dly  the  latter.  The  author  has  a  number  of  times  re- 
moved wilboul  ill  effect  part  of  one  vagus  when  it  w-as  suspiciously 
close  to  the  in\'olved  area.  The  pharyngeal  wall  is  carefully  cut  away 
with  the  scissors,  being  careful  to  save  all  of  the  mucosa  and  submucosal 
tissues  possible,  in  order  to  make  the  strongest  possible  wall  when  the 
[iharynx  is  sutured  after  removal  of  the  larynx.  Usually  the  tips  of  the 
horns  of  the  thyroid  cartilage  are  cut  off  and  left.  The  thyrohyoid  mem- 
brane is  incised  and  the  aryepiglottic  folds  are  clipped  free  with  the 
scissors.  .Ml  hemorrhage  is  carefully  arrested  at  each  stage  of  the  opera- 
tion ;  a  clean,  drv  wound  being  essentia!  to  acctirate  work.  The  pharynx 
is  now  sutured  with  silk,  being  careful  not  to  jierforate  the  mucosa,  the 
edges  of  which  are  inverted.  Then  each  layer  of  the  soft  tissue  is  care- 
fully stitched  into  place  so  as  to  afford  the  greatest  possible  support  to 
withstand  the  strain  of  deglutitinn.  I'.efore  stitching  the  skin,  the  Els- 
berg  insufflation  catheter,  or  the  anesthesia  cannula,  either  of  which,  up 
to  this  time,  has  been  in  place  in  the  preliminary  low  tracheotomy  wound, 
is  removed  and  the  ciU  end  of  the  trachea  above  the  old  tracheotomic 
wound  is  brought  forw^ard  and  inserted  through  a  button-hole  in  the  skin 
below  the  laryngcctomic  incision.  Tf  this  incision  has  been  so  long  as  to 
extend  into  tlic  tracheotomic  skin  incision,  this  part  of  the  incision 
must  be  verv  carefullv  and  tirmly  stitched  with  tension  sutures  deep  as 


C72 


TECH  NIC  OF   LARVN'CKCTOMY. 


well  as  superficial.  The  trachea  is  then  stitched  all  around  to  the  skin 
surface.  The  preliminary  tracheotomic  incision  is  drained  by  a  wick  of 
gauze  inserted  into  the  old  wound  below  the  new  tracheal  orifice.  The 
skin  is  then  accurately  stitched  and  a  large  gauze  dressing  wrung  out  of 
mercuric  bichloride  1 :10,000  is  applied. 

As  with  malignancy,  everywhere,  it  is  useless  to  do  a  laryngectomy 
and  leave  involved  glands  in  the  neck.  The  most  favorable  time  for  the 
removal  of  the  glands  is  at  the  preliminary  tracheotomy,  because  a 
rather  extensive  neck  dissection  at  that  time  has  the  advantage  of  form- 
ing a  barrier  against  infection  of  the  mediastinum  at  the  lar}-ngectomy 
later,  and  if  the  glandular  involvement  is  such  that  there  is  reason  to  be- 


Fig.  490. — Plastic  operation  for  repair  of  the  esophagus  after  verj-  extensive 
esophageal  resection  at  laryngectomy.  The  two  upper  flaps  are  turned  epidermal 
surface  inward.  Ordinarily  the  pharyngeal  walls  can  lie  drawn  together  without 
tliese  autoplastic  dermal  flaps.     (After  Molinie.) 


lieve  that  the  mediastinal  glands  are  also  infected,  it  is  better  to  abandon 
all  hope  of  cure  and  leave  the  tracheotomy  tube  in  or  not,  according  to 
conditions.  If  d3^spnea  is  present  at  all,  it  is  better  to  leave  the  tube  in, 
for  it  will  shortly  be  required,  and  it  is  better  done  early  than  late  The 
iiistologic  examination  of  suspicious  lymph  nodes  is  always  advisable.  If 
a  lymph  node  taken  from  near  the  upper  thoracic  aperture  shows  malig- 
nant involvement,  laryngectomy  is  rarely,  if  ever,  justifiable.  The  author 
has  in  a  number  of  cases  been  able  to  discover  malignant  nodes  along  the 
side  of  the  party  wall,  and  in  the  mediastinum  by  esophagoscopy  (q.  v.). 
After-care.  Antibechics  and  all  opium  derivatives  must  be  forbidden. 
Feeding  should  be  bv  a  soft  rubber  catheter  or  very  small  stomach 
tube  passed  through  the  mouth.  Plenty  of  fluid  must  be  given.  The 
external  dressings  are  renewed  every  three  or  four  hours,  because  it 
is  impossible  to   prevent  their   lieing  soiled   bv   the  contiguous   tracheal 


TKCHXIC   OF    LARYNGECTOMY.  fi73 

oi)eniiig.  The  tracheal  dressings  are  of  sejjarate  pieces  of  gauze,  re- 
newed as  ad\i<e(l  under  tracheotomy.  The  tracheal  cannula  is  kept  in 
place  in  the  end  of  the  amputated  trachea,  but  as  the  latter  is  stitched 
to  the  skin  there  is  no  wound  to  pack  open.  The  wick  of  gauze  in  the 
lower  end  of  the  laryngectomic  incision  is  removed  and  renewed  with 
the  (h'essings  every  three  hours,  and  discontinued  when  drainage  is  no 
longer  needed.  If  the  ]5haryngeal  wound  break  down,  the  lower  stitches 
of  the  skin  wound  must  be  opened  and  free  drainage  of  pharyngeal  secre- 
tions by  fresh  dressings  inserted  every  hour.  'Jlie  patient  should  be 
prop.ped  up  in  bed  on  the  second  day  and  gotten  out  of  bed  on  the  fourth 
or  filth  (lav.  Ordinarilv  the  feeding  tube  may  be  abandoned  and  the 
patient  permitted  to  swallow  strained  sterile  lic|uid  food  in  small  sips 
at  the  end  of  a  week  or  ten  days. 

Esophageal  resection.  If  removal  of  much  of  the  anterior  esophageal 
wall  is  rei|uired  autoplastic  repair  with  dermal  flaps  (Fig.  490)  may  be 
rec|uired.  The  esophagus  is,  surgically,  one  of  the  most  intolerant  organs 
in  the  body  :  and,  moreover,  recurrence  of  malignancy  is  almost  certain. 
Therefore  esophageal  resection  is  rarely  advisable. 

The  dermal  flap  operation  (Fig.  4!I0)  is  best  adapted  to  female  pa- 
tients. In  males,  hair  from  the  epidermal  flaps  may  require  frequent 
endoscopic  removals. 

Complications.  ()perative  complications  are  now  relatively  rare. 
Streptoccemia  and  jjulmonary  comi^Iications  which  by  older  methods 
were  so  frequent  are  now  seldom  seen.  Profound  shock,  weak  and  rapid 
pulse,  slight  temijerature  elevation,  ])rofound  depression,  white  or  ashy 
gray  com])lcNion,  out  of  all  i)roportion  to  the  usual  post-operative  re- 
action are  symptoms  denoting  acute  esophagitis,  vagitis  or  sejjtic  medias- 
linitis.  Beyond  stimulants  and  Incal  drainage  of  necrotic  areas,  treat- 
ment is  of  little  avail. 

.liiilicidt  laryiLV.  .Must  patients  abandon  the  use  of  a  iirothetic 
aiijiaratus  and  devote  themseh'cs  to  the  de\'eloi]nient  of  a  buccal  \()ice. 
The  most  satisfactory  apparatus  is  that  of  Sir  Robert  Woods  of  Dublin. 
Next  to  this  in  eiricicncv  is  that  of  (iluck. 


CHAPTER    XLVI. 

Bibliography. 

1.  Abraham,  Joseph  H.  Direct  Laryngoscopy,  Tracheobronchos- 
copy and  Esophagoscopy  with  Demonstrations.  Ala.  Med.  Jour.,  July, 
1908. 

2.  Abrand,  Dr.  Diagnosis  of  Foreign  Bodies  in  the  Respiratory 
Tract.     Archiv.  Gen.  de  Med.,  \'oI.  XCI,  Xo.  9.  Sept.  1912,  p.  7S3. 

3.  Adam,  James.  Asthma.  P^ublished  by  Henry  Kimpton.  Lon- 
don, 1913. 

4.  Albrecht,  W.  Surgical  Treatment  of  Tuberculosis  of  the 
Larynx.  Ztschr.  f.  Ohrenh.,  u.  f.  Krankh.  der  Luftw.,  Bd.  (il.  Heft  2, 
1910. 

.■).  Albrecht,  T.  Die  Direkte  Laryngo-Tracheo-Bronchoskopie 
und  ihre  Bedeutung  fiir  Diagnose  und  Therapie.  Med.  Klinik,  Dec. 
12,  1909. 

().  Albrecht.  A  Modification  of  Suspension  Laryngoscopy.  Berl. 
Klin.  Woch.,  July  S,  1912,  \'ol.  XLIV,  Xo.  28,  p.  1331. 

7.  ArrowsmiTH,  H.  Case  of  Apparently  Primary  Intra-Lar}ngeal 
Actinomycosis.    The  Laryngoscope,  Oct.,  1910. 

8.  Arrowsmith,  H.  Angioneurotic  Edema  of  the  Esophagus. 
Transactions  Amer.  Laryngol.,  Rhinol.  and  Otol.  Soc,  1915.  Also,  Pro- 
ceedings Amer.  Med.  Assn.,  Lar}'ngologic  Section,  1914. 

9.  Arrowsmith,  H.  (Brooklyn.)  Certain  Aspects  of  Rhinolaryn- 
gology  and  their  Relation  to  General  Medicine.*  X^.  Y.  Med.  Journ., 
Dec.  17,  1910.  Read  at  the  Xov.  1910  meeting  of  the  Med.  So.  of 
County  of  Kings. 

lit.  Arslan.  Removal  of  Foreign  Body  from  Bronchus  by 
Direct  Bronchoscopy.  (Broncoscopia  Diretta  con  Estrazione  di  Corpo 
Estraniero  del  Broncho).    Rev.  Crit.  di  Clin.  Med.,  Sept.  24,  1910. 

11.  Anders  and  Boston.  Text  book.  Med.  Diag.  Article  on  Gas- 
troscojiv,  p.  417. 


BIBLIOGRArilV.  (i7.") 

12.  AuKR  AND  MiXTziCR.  Insufflation  Anesthesia.  Med.  Record, 
\'ol.  LX.W'II,  p.  477.     Also  Bulletins  Rockefeller  Institute. 

18.  Arrovvs.mitii,  H.  Intralaryngeal  Actinomycosis.  The  Laryn- 
goscope, Oct.,  Jit  10. 

14.  Albrix'ht,  W.  Suspension  Larynjjoscopy  in  Children.  Jour- 
nal of  Laryngologj',  February,  IPM. 

1!>.  BoYCK.  John  \V.  Foreign  Bodies  in  the  Lungs  Simulating 
Pleural  Effusion.     Med.  Record,  Oct.  14,  1!)11. 

"i^ii.  I!.\r,  Louls.  Traitement  (ialvanoplastique  de  la  Tuberculose 
du  Larynx.     Proc.  Belgian  Laryngological  Society,  1!)1.'5. 

21.  Ballenckr,  W.  L.  Di.seases  of  the  Nose  and  Throat.  Pub. 
by  Lea  and  Febiger. 

22.  Bannks,  F.  The  Diagnosis  of  Foreign  Bodies  in  the  ISronchi, 
w  itli  Re|)ort  of  a  Case  of  Wandering  of  a  Foreign  Body  from  the  Right 
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172.  Gray,  A.  L.  Remarks  on  X-Ray  Technic  in  the  Treatment 
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173.  Greene,  D.  C.  Laryngotomy  and  Laryngectomy  for  Cancer. 
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174.  Green,  A.  S.  and  Lack,  H.  L.  Subglottic  Laryngeal  Tumor. 
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175.  Grifeith,  J.  P.  C.  and  Lavenson,  R.  S.  Case  of  Congenital 
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177.  Grove,  W.  E.  Tracheobronchoscopy  in  Diagnosis  and  Tr^at- 
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182.  GuiSEz.  Removal  by  Bronchoscopy  of  Foreign  Bodies  in 
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183.  GuiSEZ.  Broncho-Esophagoscopy  in  Diagnosis  of  Aneurism 
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214.  HERYNG,  TiiEodork.  Laryngeal  Arthritis.  (Gosiec  Krtani) 
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219.  Jngersoll,  J.  M.  Primary  Malignant  Growth  of  the  Trachea. 
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220.  IwANuEi",  A.  Technic  of  I^aryngostomy.  Ztsclir.  f.  Laryn- 
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221.  Iglauer,  Samuel.  Electro-Magnets  in  the  Extraction  of 
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222.  Iglauer,  Samuel.  Three  Cases  of  Foreign  Body  in  the 
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223.  Igl.\uER,  Samuel.  Tracheobronchoscopy — With  Report  of 
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224.  IGL.A.UER,  Samuel.  Foreign  ISody  in  Larynx  and  Trachea 
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225.  Ingals,  E.  F.  Tacks  and  Xails  in  the  Air  Passages:  Bron- 
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226.  Ingals,  E.  F.  Treatment  of  Foreign  Bodies  in  the  Esii|)h- 
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227.  Ingals,  E.  F.  Bronchoscopy  and  Esophagoscopy :  The 
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233.  Jackson,  Chevalier.  Foreign  Bodies.  The  Aid  of  Esoph- 
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of  a  Case.     PennsyKania  Med.  Journ.,  June,  I'.iOT. 

2o~).     J.\cks()N,  Chkvai.ii;k.     Insufflation         Anesthesia.     Editorial.      [ 
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23(1.  Jackson,  Ciiev.vliKR.  Bronchoscopy  and  L:npha,ioscnpy. 
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237.  Jackson,  Chi-:\'.\liKr.  Statistics  of  Seventy  Cases  of  (^as- 
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238.  Jackson,  Cukv.m.ikr.  The  Dilatation  of  Bronchial  Stric- 
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239.  Jackson,  Ciii'VAI.iKR.  Gastroscopy.  .\rchives  Internation- 
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210.  J.'\CKSON,  CuUv.M.ii'u.  \'oluniary  Aspiration  of  a  Foreign 
Body  into  the  Bronclii.  Renio\al  hy  Bronchoscopy.  The  Laryngoscope. 
St.  Louis,  Dec,  1909. 

241.  Jackson,  Ciii:v.M,ii;k.  Esophageal  Stenosis  F'ollowing  the 
Swallowing  of  Caustic  .\lkalies.  Journ.  of  .\.  !\I.  A.,  Nov.  20,  1910,  \'ol. 
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212.  Jackson,  Ciii;v.m.ikr.  Laryngeal.  Bronchial  and  Esophageal 
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213.  Jackson.  Chi-aai.ikk.  The  Brondioscope  as  an  .\id  in  Gen- 
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252.  Jackson,  Chevalier.  The  Larynx  in  Typhoid  Fever.  Am. 
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253.  Jackson,  Chevalier.  Primary  ^lalignant  Disease  of  the 
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254.  Jackson,  Ciievalie:r.  Thyrotoniy  and  Laryngectomy  for 
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255.  Jackson,  Chevalier.  Thymic  Tracheostenosis,  Tracheos- 
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256.  Jackson,  Chevalier.  Esophagoscopic  Removal  of  Open 
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257.  Jackson,  Chevalier.  The  Surgery  of  the  Esophagus,  Laryn- 
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258.  Jackson,  Chevalier.  Anesthesia  for  Peroral  Endoscopy. 
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259.  Jackson,  Chevalier.  Some  Problems  of  Direct  Laryngo- 
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260.  Jackson,  Chevalier.  Laryngeal,  Bronchial  and  Esophageal 
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261.  Jackson,  Chevalier.  Bronchoscopic  Aid  in  Thoracotomy, 
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262.  Jackson,  Chevalier.  Esophagoscopy  and  Gastroscopy.  The 
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263.  Jackson,  Chevalier.  Decannulation  and  Extubation  after 
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264.  Jackson,  Chevalier.  Tracheobronchoscopy.  Journal  of 
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265.  Jackson,  Chevalier.  Esophagoscopy  and  Gastroscopy.  Ref. 
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267.  Jackson,  Chevalier.  Bronchoscopy.  Ref.  Handbook  Med. 
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268.  J.\CKSON,  Chev.vliER.  Laryngeal  Stenosis  from  Post-typhoid 
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277.  Johnston,  R.  U.  Straight  Method  of  Direct  Laryngoscopy. 
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288.  Jaxeway.  H.  H.  and  Green,  X.  \\'.  Cancer  of  the  Esoph- 
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299.  Kahler,  Otto,  bronchoscopy  and  Esophagoscopy.  Laryn- 
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Journ.  Eye,  Ear  and  Throat  Diseases.     Nov.,  1905. 

.■>77.  WisHART,  D.  J.  Ci.  Esophagoscopy  and  Trachcobronchoscoi)y. 
Dom.  .\lcd.  Monthly,  Se])t.,  1909. 

•)78.  Woi.vTCHEK,  \'.  Experiences  d'lntroduction  dc  Corps 
Etranger  dans  les  Bronches  chez  les  Animaux.  .Archiv.  Internat.  de 
Laryngol.,  etc.  (Chauveau)  July-August.  liHI. 

.i79.  Wood,  Geo.  B.  The  .Actual  Cautery  in  the  Treatment  of 
Localized  Tuberculous  Lesions.  .Annals  of  Otology,  Rhinology  and 
Laryngology,  Sept..  I'.ill. 

580.  Woods,  Sir  Robert.  Two  Cases  of  Subglottic  Tumor. 
Journ.  Laryngology,  Rhinol.  Otol.,  Oct.,  191.'!. 

•"iSl.  Woni,si:v.  Wm.  Intratracheal  Insufllation  .Anesthesia.  Read 
before  the  X.  Y.  Society  of  .Anesthetists,  March  ti,  1912. 

.■iS2.  \\'uiGHT,  J.  Microscopical  Diagnosis  of  the  Intralaryngeal 
Growths  from  a  Practical  Standpoint.  The  Laryngoscope,  .\ug.,  1909, 
and  X.  ^■.  Med.  loiir..  lulv  17.  lMo:t. 


703  I5IELI0GRAPHV. 

583.  W'iSHART,  D.  J.  G.  BronchosLopy  and  Esophagoscopy.  Can- 
ada Lancet,  Feb.,  1909. 

584.  Wherry,  \V.  P.  Removal  of  Foreign  Bodies  from  the  Respira- 
tory Tract  by  Laryngoscopy  and  Esophagoscopy.  Western  Aled.  Rev., 
Sept.,  1913. 

585.  \\'ooD,  George  B.  Pathology. of  Foreign  Bodies  in  the  Lungs. 
Philadelphia  Monthly  Med.  Journ.,  June,'lS99. 

586.  Wells,  Walter  A.  Thyroid  Gland  Tumors  of  the  Larynx. 
Journ.  of  Laryngology,  Oct.,  1903. 

587.  Wadsack  and  Kob.  Echinococcus  of  the  Left  Lung.  Berlin 
Klin.   Woch.   p.   1097,   No.  33,   190G. 

593.  YankauEr,  vS.  Foreign  Body  Removed  from  the  Bronchus. 
The  Laryngoscope,   Nov.,  1910. 

591.  Yankauer,  Sidney.  A  New  Safe  Procedure  in  Bronchos- 
copy.   Arch.  f.  Laryn.  u.  R.,  Bd.  NX\'L  Heft  3,  p.  708. 

595.  Yankai.-er,  SinxEv.  Three  Cases  of  Foreign  Body  in  the 
Bronchus.     The  Larj^ngoscope,  Oct.,  1912.  \'ol.  XXIL  No.  lo.  p.  121s. 

59().  YankauER,  S.  Foreign  Body  Cases.  Discussion.  Proc.  Am. 
Laryngol.  Rhinol.  and  Otol.  Soc,  1913,  p.  331. 

fiOO.  Zimmerman,  Alfred  (Heidelberg).  Lispired  Foreign  Bodies. 
Zeit.  f.  Laryn.,  u.  f.  Krank.,  etc.,  Bd.  LNVH,  No.  1-2,  p.  19. 


BIBLIOGRAPHY  OF  SUSPEXSU  ).\  LARYNGOSCOPY. 

Albrecht:     Suspension-laryngoscopy  in  Children. 

Association  of   Charite  Physicians.      Meeting  May  2.    I'.il2.      Bcr- 
lincr  Klin.    JVochensclir..   No.    27,   49,   \'ol.    I.    July,    1912,   p. 
1295-9G. 
Albrecht:     A   Modification  of   Suspension-laryngoscopy. 

From  the   University   Polyclinic   for   Nose  and  Throat   Patients   in 
Berlin.     Berlin.   Klin,    li'ochcn.u-hr.,   No.   28,  V.K  \'ol.   8,   July, 
1912,  p.  1331-32. 
Albri:ci!T:    .\  New  Spatula  for  Suspension-laryngoscopy. 

Berliner  Klin.   Woiiirnschr.,  No.  41,  1SI12.     Senion's  Inteniat.  Cen- 
tralhl.  f.  Laryn(/ol.,  Rhinol.   n.   veriK.'.    ]]'isscn.<^ch.,   X'ol.   XNIX, 
January,  191.3,  No.  L  P-  5. 
Albrecht:     The  Imi)ortance  of  Suspension-laryngoscojiy  for  Children. 
Archil .  f.  Laryiifiologie  ii.  Rhinoloijic,  \'ol.  28,  p.  1.. 


BIBLIOGRAPHY.  703 

Ri.i- M  kxi'kld:     Control  of   Haemorrhage   in   the   Larynx   by   means   of 
Clamp-stitch. 
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Medical  Record,  February  22,  1913. 
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Arch.  f.  Laryncjologie,  Vol.  27,  p.  459. 
Fro.ving  :    Suspension-lary-ngo.scopy. 

General  Medical  Society  of  Cologne.       Mncnch.  nicd.  U'ochcnschr.. 
1913,  p.  1742. 
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of  the  Respiratory-  Passages,  Incl.  Suspension-laryngoscopy. 
Society  of  Scientific  Therapeutics.  Kocnigsbcrg  i.  Pr.  Official  Min- 
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1913.  \'ol.  39,  Xo.  13,  p.  (;2(). 
Hen'RICH  :    Contribution  to  the  Clinic  of  Direct  .Methods  of  Examination. 

.Muenchn.  Mcdicin.  U'ochcnschr.,  Xo.  48.  1913. 
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1912. 
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Society  of  Charite  Physicians.     Meeting  of  May  2,  1912.     Berliner 
Klin.  U'ochcnschr.,  Xo.  27,  \'ol.  4!),  July  1.  1912.  p.  12!M-95. 


704  BIBLIOGRAPHY. 

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Hoelscher: 

Transactions  of  the  Society  of  German  Laryngologists,  191:!,  p.  144. 
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Mucnchn.  Med.  Woehcnselir.,  191;^,.  p.  1742. 
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Lancet,  July   19,   1913.     Semon's  Internal.   Centralbl.  f.   Laryngol., 
Rhhiol.  n.  veriv.  IVisscnseh,  \'o\.  XXIX,  Nov.  1913,  No.  11,  p. 
550. 
IglauER,   Samuel  :     Foreign   Bodies  in  Larynx   and  Trachea  Removed 
by  the  Aid  of  Suspension-laryngoscope. 
The  Laryngoseope,  June.  1913.         Semon's    Internal.    Centralbl.    f. 
Laryngol.,  Rliinol.  u.  verie.  ll'issenseli.  Dec,  1913.  \'ol  XXIX, 
No.  12,  p.  GOl. 
Kaempeer.  Louis  G.  :    Suspension-laryngoscopy. 

A'eiv  York  Medical  Journal,  Jan.  4,  1913.     Semon's  Internat.  Cen- 
trbl.  f.  Laryngol.,  Rlunol.  u.  verxe.  U'issenscli.  \'ol.  XXIX,  June 
1913,  No.  fi,  p.  285. 
Kahler,  Otto:    Tlic  Chirurgical  Intra  and  Extra  Laryngeal  Treatment 
of  Laryngeal  Tuberculosis. 
Ref.      Delivered    at    the    H~nh    Meeting    of    Xaturalists    in    \'ienna 
(p.  12T5).     Monatsselir.  f.  Ohrenheitkinide  n.  Laryniio-Rliinol- 
ogie,\'n\.  XIA'II,  19]:;,  pp.  Ti(;!)-l2s:i. 
Katzenstein  : 

Transactions  of  the  Society  of  German  Laryngologists,  1913,  p.  143. 
KiLLiA^:     Suspension-laryngoscopy.      A    Modification    of    the    Direct 
iMethod. 
Transactions   of    the    III    International    Laryngo-khinological    Con- 
gress, Berlin,   .August  :iii-Septeml)er  2,    liMl,  ji.    112,   Part   II: 
Transactions. 

Killian:     On   Susy)ension-laryngoscoi>y. 

Berlin.  Klin.   W ochenschr.,   Xo.   13,   1912.     Semon's   Internat-    Cen- 
trbl.  f.  Laryngol.,  Rhinol.  n.  z'erw.  ll'issenseli.  \  ol.  XXIX,  Jan- 
uary, 1913,  No.  ],  p.  5. 
KiLLiAX  :     On  Suspension-laryngoscopy. 

Society  of  Charito  Physicians,  Meeting  of  May  2,   1912.     Berliner 
Klin,  ll'oeliensclir..  Xo.  27,  \'ol.  19.  July  1,  l!n2,  p.  1293-94. 


Bir.I.KIGRAl'llY.  705 

KiLLiAN,  GusTAv:     Suspension-laiviigoscopy. 

Rc'iniiit  fnim  the  .Ircli.  of  Larymju!.  and  RliinoL,  \'ol.  ■>ti,  Xo.  "-i,  Uer- 
liii.  1912. 
Kii.i.iAx;     ( )n  Suspension -larynsjoscopy. 

Berlin.  Klin.  U'uchdisclir.,  No.  27,  p.  1293,  1912.    Semon's  Internal. 
Ccntrbl.  f.  LarynyoL,  Rhinol.  u.  vcriv.  Wisscnscli.,  \'o\.  XXIX, 
January,  1913,  No.  1,  p.  ."). 
KiLLiAN  :     The  Suspension-hook  in  its  Newest  Form. 

Transactions  of  the  Society  of  German  Laryngol.,  1913,  p.  25. 
KiLLiAN  :     Demonstrations  of  Suspension-laryngoscopy. 

Transactions  of  the  Internat.  Med.  Congress,  London,  1913. 

KlI.LIAN  : 

Naturahsts'  Meeting,  X'icnna,  1913,  Laryngol.  Section. 
Kii.Li.\N :     On  Suspension-laryngoscopy. 

1913,  Berliner  Klin.  ll'ochcn.<;chr. 
Klkstadt : 

Berlin.  Klin,  ll'ochenschr.,  1913,  No.  3,  p.  133. 
Lautf.nschlaeger  : 

Berlin.  Klin.  W'ochcnschr.,  1913,  p.  4-18. 
Mann  : 

Transactions   of    the    Society    of    German    Laryngologists,  1913,   p. 
144. 
M.\^'i:k,  E.  :     Removal  of  a  Carcinoma  of  the  Epiglottis  by  Suspension- 
laryngoscopy. 

Arch.  f.  Laryngol,  p.  r)92,  \'o].  27,  No.  3. 
Poi,i..\tsciii-:k  :    Direct  C)perations  upon  the  I.ar\n.\. 

Orvosi  hctihif'..  No.  49,  1912. 
vSkiki'Krt  :     The  Killian  Suspensioti-Iaryngoscop}-. 

Zeitschr.  /'.  Laryngoloyie  ii.  Rliinolof/ie,  VL  H.  4,  1913. 
SiEGEL:  Twilight  Sleep  in  Obstetrics  with  Sdlulions  of  Skoinilaniine. 

Muenclm.  Medic.  JVoclicnsclir.,  1913. 
SiMDi.i'Ki :     Laryngeal   Scleroma   Treated   by    Suspension-laryngoscopy. 
Monatschr.  f.  Ohrcniieilk.  ti.  Laryngo-Rhinologie,  Vol.  XLVH, 
No.  7,  p.  9S9. 
Sti-i.nkr  :     C)n  Suspension-laryngu.scopy. 

I'rager  Medicin.  IVochenschr.,  1913,  No.  28. 
Storatii  : 

Muenclm.  Mcdiz.  H'oclicn.schr.,  1913,  p.  325. 
Straitb:    On  Decomposition  and  Conservation  of  Skoiiol.uiiine  Sdluliuns. 

Muenclm.  Med.  IVochenschr.,  1913,  No.  41. 
W'OT.EF,  J.  H.;  Demonstration  (if  an  Apparatus  for  Suspension-larvngos- 

I'CIJIV. 

Laryngological  Society  of  Berlin,  Meeting  of  April  19,  I91J.    Berlin. 
Klin  Jl'ochrnschr.,  June  10,  1912.  No.  24,  Vol.   19,  p.  ll.M. 


Description  of  Colored  Plates. 

PLATE  I. 

LARYNGEAL   AND   TRACHKAL   STENOSES. 

1.  Direct  view.  Sitting  position.  Male,  aged  14  years.  Post- 
diphtheritic cicatricial  stenosis  cured  by  endoscopic  evisceration.  (See 
Fig.  5.)   Known  to  be  well  two  years  after  decannnlation. 

2.  Direct  view.  Sitting  position.  Male,  aged  18  years.  Post- 
typhoid cicatricial  stenosis,  ^lucosa  was  very  cyanotic  because  cannula 
was  removed  for  laryngoscopy  and  bronchoscopy.  Cured  by  laryn- 
gostomy  (See  Fig.  G).  Still  well  four  years  after  decannnlation  and 
plastic  closure. 

3.  Direct  view.  Sitting  position.  Male,  aged  37  years.  Post- 
typhoid infiltrative  stenosis.  Left  arytenoid  destroyed  by  necrosis.  Cured 
by  laryngostomy.  Failure  to  form  adventitious  band  (Fig.  7)  because 
of  lack  of  arytenoid  activity. 

4.  Direct  view.  Recumbent  position.  Male,  aged  40  years.  Post- 
typhoid cicatricial  stenosis.  Cured  of  stenosis  by  endoscopic  eviscera- 
tion with  sliding-punch  forceps.  Anterior  commissure  twice  afterward 
cleared  of  cicatricial  tissue  as  in  other  case  shown  in  Fig.  l-").  Ultimate 
result  shown  in  Fig.  S. 

•5.  Same  patient  as  Fig.  1.  Sketch  made  two  years  after  decan- 
nnlation and  plastic. 

G.  Same  patient  as  Fig.  3.  Sketch  made  four  years  after  decan- 
nnlation and  plastic. 

7.  Same  patient  as  Fig.  3.  Sketch  made  three  years  after  decan- 
nnlation and  plastic. 

8.  Same  i>atient  as  Fig.  4.  Sketch  made  one  year  after  decan- 
nnlation, fourteen  months  after  clearing  of  the  anterior  commissure  to 
form  adventitious  cords. 


(g)(i)(|) 


PLATE  I. 

Direct    laryngoscopic    views.      Photoj^'raphic  reproduction  of    oil    color- 
drawintjs  from  life  by  the  author.      For  description,  see  previous  pages. 


QO(S>©® 


PLATE  II. 

Direct  and  indirect  laryngeal  views.     Photographic  reproduction  of  oil 
color-drawings  from  life  by  the  author.     For  description,  see  previous  pages. 


DESCRIPTION    OF   COLOR    PI.ATliS.  707 

9.  Direct  \ic\v.  Kccumheiit.  Female,  aged  1(1  years.  W  eb  post- 
dii)htlieritic  (?)  or  congenital  (?).  "Rough  voice"  since  birth  Imt 
larynx  never  examined  until  stenoscd  after  diphtheria.  W'eh  removed 
and  larynx  eviscerated  with  punch  forceps.  Recurrence  of  stenosis  (not 
of  web).  Cure  by  laryngostomy.  This  view  also  illustrates  the  true 
depth  of  the  larynx  which  is  often  overlooked  because  of  the  misleading 
flatness  of  laryngeal  illustrations. 

10.  Direct  laryngoscopic  view.  Child,  aged  22  months.  Post- 
dijjhtheritic  hypertrophic  subglottic  stenosis.  Cured  by  galvano-cauteri- 
zation. 

11.  Direct  laryngoscopic  view.  Child,  aged  three  years.  Post- 
di[)htheritic  hypertrophic  supraglottic  stenosis.  Forceps  excision, 
b'-xtiibation  one  month  later.     Still  well  four  years  later. 

12.  r»ronchoscopic  view  of  post-tracheotomic  stenosis  foHowing' a 
"plastic  flap"  tracheotomy  done  for  acute  edema.  Male,  aged  17  years. 
(Not  treated  because  of  advanced  nephritis). 

1.3.  Direct  laryngoscopic  view.  Anterolateral  thymic  compression 
stenosis  in  a  child  of  IS  months.  Cured  by  thymopcxy.  Seen  six  months 
later.     Still  well. 

II.  Indirect  laryngoscoi)ic  ( mirror  i  view.  I.aryngostomv  ruliber 
tube  in  position  in  treatment  of  post-typhoid  stenosis.  W'nnian,  aged 
30  years. 

15.  Direct  \iew.  Post-typhoid  stenosis  after  cure  b\'  laryngostomy. 
Male,  aged  30  years.  Dotted  line  shows  place  of  excision  for  clearing 
out  the  anterior  commissure  to  restore  the  voice. 

in.  Endosco]iic  \icw  of  post-tracheolomic  tracheal  stenosis  from 
badly  placed  incision  and  chondrial  necrosis,  in  a  child  of  three  years. 
Tracheotomj-  originally  done  for  influenzal  tracheitis.  Cured  by  tracheos- 
tomy. 

PL.M'K  II. 

DIRKCT    \.\I>   INl)IU::ci'    I..\ltVi\"C.K.\l.  VIICWS. 

Fig.  I.  Ki)igloltis  of  child  as  seen  b\-  dircci  laryngoscopy  in  the 
recumbent  i>osition.  2.  .Normal  larynx  spasmodically  closed  as  is  usual 
on  first  exposure  without  anesthesia.  3.  Same  on  inspiration.  I.  Supra- 
glottic  papillomata  as  seen  on  direct  laryngosco|)y  in  a  child  of  two 
years.  5.  Cyst  of  the  lai"ynx  in  a  child  of  four  years,  seen  on  direct 
laryngoscopy  without  anesthesia,  (i.  Indirect  \icw  of  larynx  eight  weeks 
after  tbyrcjtoniy  for  cancer  of  the  right  cord  in  a  man  of  tift\-  years. 
7.  Same  after  two  vcars.     .\n  a<l\cntitious  liand   indistinguish.-dile   troni 


T08  DESCRIPTION   OF  COLOR   PLATES. 

the  original  one  has  replaced  the  lost  cord.  <S.  Represents  the  condition 
of  the  larynx  three  years  after  hemilaryngectomy  in  a  patient  fifty-one 
years  of  age.  Thyrotomy  revealed  such  extensive  involvment,  with  an 
open  ulceration  which  had  reached  the  perichondrium  that  the  entire  left 
wing  of  the  thyroid  cartilage  was  removed  with  the  left  arytenoid.  A 
sufficiently  wide  removal  was  accomplished  without  removing  any  part 
of  the  esophageal  wall  below  the  level  of  the  crico-arytenoid  joint.  There 
is  no  attempt  on  the  part  of  nature  to  form  an  adventitious  cord  on  the 
left  side.  The  normal  arj^tenoid  drew  the  normal  cord  over,  approxi- 
mately to  the  edge  of  the  cicatricial  tissue  of  the  operated  side.  The 
voice,  at  first  a  very  hoarse  whisper,  eventually  was  fairly  loud,  though 
slightly  husky  and  inflexible.  !>.  Mouth  of  the  esophagus  one  year  after 
laryngectomy  for  endothelioma  in  a  man  aged  sixty-eight  years.  The 
purple  papillae  anteriorly  are  at  the  base  of  the  tongue  and  from  this 
the  mucosa  slopes  downward  and  backward  smoothly  into  the  esophagus. 
There  are  some  slight  folds  toward  the  patient's  right  (to  the  left  in 
the  illustration)  and  some  of  these  are  quite  cicatricial.  The  epiglottis 
was  removed  at  operation.  The  trachea  was  sutured  to  the  skin  and 
did  not  communicate  with  the  pharynx.    Indirect  view. 


PIRATE  III. 

ES0PH.\G0SCOPIC  VIEWS. 

1.  Direct  view  of  the  larynx  and  laryngophars'nx  in  the  dorsally 
recumbent  patient,  the  epiglottis  and  hyoid  bone  being  lifted  with  the 
direct  laryngoscope^  or  the  esophageal  speculum.  The  spasmodically 
adducted  vocal  cords  are  partially  hidden  by  the  overhang  of  the  spas- 
modically adducted  ventricular  bands.  Posterior  to  this  the  aryepiglottic 
folds  ending  posteriorly  in  the  arytenoid  eminences  are  seen  in  apposi- 
tion. The  esophagoscope  shottld  be  passed  to  the  right  of  the  median  line 
into  the  right  pyriform  sinus,  represented  here  by  the  right  arm  of  the 
dark  crescent. 

2.  The  right  pyriform  sinus  in  the  dorsally  recumbent  jiatient.  The 
eminence  at  the  upper  left  border  corresponds  to  the  edge  of  the  cricoid 
cartilage. 

;i.  The  cricopharyngeal  constriction  of  the  esophagus  in  the  dor- 
sally recumbent  patient,  the  cricoid  cartilage  being  lifted  forward  with 
the  esophageal  si)eculum.  The  lower  (posterior)  half  of  the  lumen  is 
closed  by  the  fold  corresponding  to  the  orbicular  fibers  of  the  cricophar- 
yngeus,  which  advances  spasmodically  from  the  posterior  wall.  (Com- 
pare Kig.  10).    This  view  is  not  so  clearly  obtained  with  an  esophagoscope. 


5  6  7  8 

ESOPHAGOSCOPIC    VIEWS.    NORMAL. 


m 


10 


\z 


13  14  15  16 

ESOPHACOSCOPIC  VIEWS.  ABNORMAL. 


PLATE  III. 

I'lioto^rapliic  reproductions  of  tlie  author's  oil  color-clrawings  from   life. 
For  description,  see  previous  pages. 


])HSCUIPTIOX    OK   COUIK    PLATES.  709 

4.  Passing  through  tlie  right  pvriform  sinus  with  the  esophagoscope ; 
dorsally  recumbent  patient.  The  walls  seem  in  tight  apposition,  and,  at 
the  edges  of  the  slit-like  lumen,  bulge  toward  the  observer.  The  direc- 
tion of  the  axis  of  the  slit  varies,  and  in  some  instances  it  is  like  a 
rosette,  depending  on  the  degree  of  spasm. 

5.  Cervical  esophagus.  The  lumen  is  not  so  patulent  diunng  in- 
spiration as  lower  down  ;  and  it  closes  comijlctely  during  expiration. 

C>.  Thoracic  esophagus.  Dorsally  recumbent  patient.  The  ridge 
crossing  above  the  lumen  corresponds  to  the  left  bronchus.  It  is  seldom 
so  prominent  as  in  this  patient,  but  can  always  be  found  if  searched  for. 

7.  The  esophagus  at  the  hiatus.  This  is  often  mistaken  for  the 
cardia  by  esophagoscopists.  It  is  more  truly  a  sphincter  than  the  cardia 
itself,  and  in  the  author's  opinion  it  is  questionalile  if  there  is  any  truly 
spliincteric  action  at  the  cardia.  It  is  the  spasmodic  closure  of  this 
hiatal  sphincter  that   ])r()duces  the  syndrome  called  "cardiospasm."' 

S.  View  in  the  stomach  with  the  o])en-tube  gaslroscope.  The  forms 
of  the  folds  vary  continually. 

9.  Sarcoma  of  the  jjosterior  wall  of  the  upper  third  of  the  esojih- 
agus  in  a  woman  of  thirty-one  years.  Seen  through  the  esophageal  spec- 
ulum, patient  sitting.  The  lumen  of  the  mouth  of  the  esophagus,  much 
encroached  upon  by  the  sarcomatous  infiltration,  is  seen  at  the  lower 
part  of  the  circle. 

10.  Coin  (half-dollar)  wedged  at  the  upper  thoracic  aperture  of  a 
boy  aged  fourteen  years.  Seen  through  the  esophageal  speculum,  recum- 
bent patient.  Forceps  are  retracting  the  superjacent  cricopharyngeal  fold 
preparatory  to  removal  of  foreign  body. 

11.  ^'ungating,  squamous-celled  epithelioma  in  a  man  of  seventy- 
four  years.  Fungations  are  not  always  present,  and  are  often  pale  and 
edematous.  The  appearance  of  malignancy  may  be  masked  by  intlam- 
mation  due  to  mixed  infections. 

12.  Cicatricial  stenosis  of  the  esophagus  following  the  swallowing 
of  lye  in  a  b(i\'  of  four  years.  Helow  the  up|)er  stricture  is  seen  a  sec- 
ond stricture.  .\  third  one,  not  shown,  was  located  eccentrically  farther 
down.  An  ulcer  surrounded  by  an  inflammatory  areola  and  the  granula- 
tion tissue  togetiier  illustrate  the  etiology  of  cicatricial  tissue.  ■  The  fan- 
shaped  scar  is  really  almost  linear  but  it  is  viewed  in  jiersiJective.  Patient 
was  cured  by  esoi)bagoscopic  dilatation. 

1^1.  Angioma  of  the  esophagus  in  a  man  of  forty  years.  The  pa- 
tient had  hemorrhoids  and  varicose  veins  of  the  legs. 

14.  Luetic  ulcer  of  the  esophagus,  2Ci  cm.  from  the  upper  teeth,  in 
a  woman  of  thirty-eight  years  referred  for  dysphagia.    Two  scars  from 


710  DESCRIPTION   OF  COLOR   PLATES. 

healed  ulcerations  are  seen  in  perspective  on  the  anterior  wall.  Branch- 
ing vessels  are  seen  in  the  livid  areola  of  the  ulcers. 

15.  Tuberculosis  of  the  esophagus  in  a  man  of  thirty-four  jears. 
No  vessels  are  visible  near  the  grayish-white  patches.  A  specimen  of  tis- 
sue removed  esophagoscopically  was  reported  by  Dr.  Ernest  \\".  \\  illetts 
to  be  tuberculous. 

]().  I.eucoplakia  of  the  esophagus  near  the  hiatus  in  a  man  aged 
fifty-six  years. 

PLATE  IV. 

Fig.  122  and  Fig.  123.  Mews  obtained  by  suspension  laryngoscopy. 
For  descriptions  see  Chapter  \TII. 

PLATE  V. 

Upper  illustration.  A,  gastroscopic  view  of  a  gastrojejunostomy 
opening  drawn  patulous  by  the  tulie  mouth.  (Gastrojejunostomy  done 
by  Dr.  George  L.  Hays.)  B,  carcinoma  of  the  lesser  cuvalure.  (Patient 
afterward  surgically  explored  and  diagnosis  verified  by  Dr.  John  J. 
Buchanan.)  C,  healed  i)erforated  ulcer  (patient  referred  by  Dr.  John 
W.  Boyce). 

Lozver  illustration.  Drawn  from  a  case  of  post-diphtheritic  sub- 
glottic stenosis  cured  by  the  author's  method  of  direct  galvano-cauteriza- 
tion  of  the  hypertrophies.  A,  immediately  after  removal  of  the  intuba- 
tion tube,  hypertrophies  like  turbinals  are  seen  projecting  into  the  sub- 
glottic lumen.  B,  five  minutes  later.  The  masses  have  now  closed  the 
lumen  almost  completely.  The  patient  became  so  cyanotic  that  a  bron- 
choscope was  at  once  introduced  to  prevent  asphyxia.  C,  the  left  mass 
has  been  cauterized  by  a  vertical  application  of  the  incandescent  knife. 
D,  completely  and  permanently  cured  after  repeated  cauterization. 

PLATE  VI. 

Endoscopic  views  through  the  Janeway  gastroscope.  A.  Looking  in 
the  direction  of  the  pylorus.  B.  View  toward  the  fundus.  From  illustra- 
tions furnished  by  Henry  Janeway. 


c 
o 


-a 


o 


c 


o 

t- 


o 
u 


c 
o 

u 

s 

O 

u 
D. 
U 


Gastroscopic  Views. 


Direct  Laryngoscopic  Views. 
PLATE  v. 
Reproductions  of  oil  color-drawings  from  life  by  the  autlior. 


PLATE  \I. 
Views  through  the  lens-system  gastroscope.     For  descrijition,  see  previous  pages. 


INDEX 


Abscess,  bronchiectatlc,  78 

due   to   presence   of   foreign   body, 

in    right    inferior    lobe    bronchus, 
localization   of,   230 
lung,  radiograph  of,  405 
of  esophagus    from    foreign    body 

trauma,  ;io9 
pulmonary.  78 

nontuberculous,  237,  476 
retropharyngeal,  92,  185 
Actinomycosis  of  the  esophagus,  566 
Adrenalin,  56,  63 

effect  of,  on  color  of  bronchoscopic 
image,  175 
Air  passage,  removal  of  foreign  body 

from  upper,  88 
Alcohol,   117 

in    treatment 
larynx,  423 
Alcoholism,   75 
Alkalies    and    cicatricial    stenosis 

esophagus,   522 
Amyl  nitrite,   56,   59.   74 
capsule,  need   of.   46 
Amyloid  tumors  of  trachea.  433 
Analgesia  in  peroral  endoscopy,  54, 
Anatomical    knowledge    necessary 

bronchoscopy  and  esophagoscopy, 
Anesthesia,    advantages    of    slight, 
bronchoscopy,  30 

arrested  respiration  during.  473 
effect  of,  on  color  of  bronchoscopic 

image,  175 
Elsberg.   60 

esophagoscojjy    without.   193 
ether,  rectal.   64 
for  bronchoscopy  In  adults,  466 
in   children.   172,   466 
indirect  laryngoscopy  for  diag- 
nosis, 266 
in    children,     contraindication 
for,   126 
for  esoi)hagOKCopy.   55.   56.   (;o.    72. 
ISO,   492 
laryngostomy,  633 
peroral  endoscopy,  54,  72 
removal   of   benign    growth   of 

trachea,  435 
tracheotomy,  596 
work  on   dogs,  204 


of    papillomata     of 


of 


72 

for 

52 

in 


Anesthesia,  general,  60-64,  72,  89,  91,  94 
for  direct   laryngoscopy,  posi- 
tion  during,   S3 
in  dyspneic  children,  dangers 
of,  126 
fluoroscopic   foreign    body 
work,  295 
technic  for,  58,   59 
In  adolescents,  63 

bloody  oiierations,  67 
bronchoscopy,  162,  301 
buccal  operations,  67 
children  under  6  years,  72,  172 
esophagoscopy,  330,  360 
infiltration,    for    tracheotomy,    59S 
in  foreign  body  removal,  355,  356 
gastroscopy,  572 
laryngeal    operation,    67,    103 
laryngectomy,    669 
nasal  operations,  67 
pharyngeal    operations,   67 
prolonged   operations,  67 
removal     of     papillomata     of 
larynx  in  children,  425 
insufflation,  65,  66,  72,  73 

rules    for    administration    of, 
69,  72 
in  Ihyrotomy  for  malignant  laryn- 
geal disease,  661-663 
tracheotomized  patient,   599 
intratracheal      insufflation      anes- 
thesia in  thoracotomy,  320 
in    tuberculars,    152 
local,  64,  65,  94,  96 

author's  technic  for,  58 
general    rules    for,   56,    57,    58 
in    thyrotomy,   65,   662 
tracheotomy.    598 
Anesthetic  solutions,  Yankauer's  cuiis 

for,  41 
Anesthetist,   i)osition   of.  in    head  and 

neck  surgery,  67 
Anesthetizing  attachment  for  broncho- 
scope, Buchanan,  22,  59,  68 
Aneurysm,  ,53,  64,  248,  484 

invading        trachea        simulating 
tumor,  434 
Angioma,    impossibility    of    removing, 
under  cocain.  60 
subglottic,  104 
Angioneurotic  edema,  488 


INDEX. 


Anterior  commissure,  exposure  of,  94, 

100,   106,   124 
Antliracosis,  298 
Antibeeliics,  57,  aOl,  482 
Antiperistalsis,  55 
Antipyrin,   56 

Aplionia,  liysterical,  suspension  laryn- 
goscopy in,  154 
Apnea  following  tracheotomy,  598 

vera,  60,  601 
Apparatus,  Elsberg,  60,  64,  66 
Applicator,   Sajous,   64 
Argyrol  in  esophageal  diseases,  498,  499 
Arsenic     to     prevent     recurrence     of 

laryngeal  papillomata,  149 
Artificial   respiration,  56,  62,  67,  74 
Arytenoid,  accidental  removal  of  large 
part  of  left,  105 

eminence,  right,  188 
traction  of,  necessary  for   produc- 
tion of  adventitious  cord,  114 
region,  infiltration  of,  205 
Arytenoids,  94 
Aryepiglottic  fold,  93 
Asepsis,  need  of,  46 

Asphyxia   due   to   thymic  compression 
stenosis,   472-476 

tracheotomy  in,  588 
Asphyxiation,   67,   245 
Aspirating  canal,  author's,  21,  28,  29,  30 
pump,   Ingals'   electric,    28 
syringe,  28,  29 
AsiJiration,   swab,   53 
Aspirator  for  esophagoscopy,  29 

nozzle  for,  for  freeing  fauces  and 

pharynx  from  secretions,  29 
Yankauer's,   28 
Aspirators,   28-31,   163 
Assistants  during   endoscopy,   47 
Asthma,   bronchial,    478 
Atelectasis  in  foreign  body  cases,   299 
Atroi)ine,    63 

Autoplasty  after  laryngostomy,  642-644 
Autoscope,  Kirstein,  17 
Bandage  gauze  for  endoscopic  sponges. 

31 
Bands,  false,  93 

ventricular,  94,  236 
Basket,  Graefe,   452 
Batteries.  26-28 

on    operating    table,    arrangement 
of,  49 
Battery,  author's  endoscopic,  27,  28 
Bechic   blast,   236,  242 
Bismuth    for    foreign    bodies    in    stric- 
tured  esophagus,  357 
subnitrate  in  esophagitis  and  trau- 
nuitic  ulcerations,  498 
Bite  blo.k,  thimble,  38,  39,  163 
Blind  method  of  intubation,  75 
Blood,    removal    of,    during    bronchos- 
copy, 30 


Bougie,  eyed,  author's,  43 
in  esophageal  cases,  218 
filiform,     for     minute     cicatricial 

strictures  of  esophagus,  44 
olive,  Plummer's  double,  42 
Bouginage   per    tubam    in    stenosis    of 

esophagus,  532 
Bromides,  56 

Bronchi,  diseases  of,  bronchoscopy  in, 
465 

endoscopic  appearance  of,  177 

exploration  of,  163 

foreign  bodies  in,  20 

in  pneumothorax,  endoscopic  view 

of,  487 
stenosis   of,  compression.   470,  476 
Bronchial  asthma,  478 
Bronchiarctia,  477 
Bronchiectasis,  234,  248,  298,  477 

bronchoscopy   in,   465 
Bronchitis,    gangrenous,    after    aspira- 
tion of  foreign  body,  299 

due  to  chloroform  poisoning,  62 
peanut,  238 
treatment  of,  47 
Bronchoscope,  16,  19,  20,  21,  23,  30,  73, 
74,  77 
and  forceps,  preliminary   practice 

with,  201 
author's,  20,  22,  23 
Briinings,  103 

introduction  of,  174 
Buchanan's  dosimetric  anesthetiz- 
ing attachment  for  the,  22,  484 
correct  holding  of,  168 
depth  of  insertion  in,  171 
held  in  left   hand,   166 
incorrect  holding  of,  168 
Ingals'  distally  illuminated,  12,  13 
in  position  after  removal  of  laryn- 
goscope,  167 
recumbent      patient.      antero- 
posterior and   lateral  radio- 
graph of,  223 
right  and   left   main   bronchi 

entering  the.  169 
upper     lobe    bronchus,     radio 
graph  of.  165,  222 
into   middle   lobe   bronchus,   enter 
ing,  170 
right   and   left   main    bronchi 

entering.  169 
upper  lobe  bronchus,  entering, 

171,    172 
various    branch    bronchi,    en 
tering,  170 
in  trachea,  position  of.  during  ar 

tificial  respiration,  74 
introduction  of,  58,  59,  70,  75,  155- 
177 
difficulties  in.  161 


INDEX. 


Bronchoscope,  introduction  ol',  patient 
recumbent,  157 

sitting,  15.T 
through   glottis,  159 
Kaliler,  K5,  103 

introduction  of,  175 
removal  of    254 
sizes    of,   20,   21,   22 
slanted  end,  lti9,  170 

for  entering  branchi    bronchi, 
172 
sliding     double-tubo,     of     Schoon- 

maker,  13 
use    of     author's,     for     subglottic 
laryngoscopy  in  children,  102 

Bronchoscopic   appearance   in    disease, 
467 

image,  normal,  175 
oxygen   insufflation,   73 
picture  in  asthma,  478 
removal     of    benign     growths     of 
trachea,  434 

Bronchoscopy,   17,  25,  30,  32,  60,  68,84,92 
best   time  for,  301 
Boyce  position  during,  advantages 

of,   1(J4 
by   Briinings'    method,   173 
contraindicationo    for,    466 
dilTuulties  of,  200 
during   tracheotomy,  601 
fatigue  in  children  after,  262 
lluoroscopic,  295,  303 
for    forf'ign    bodies,    complications 
and    after-effects  of,   258-265 
in  children,  fil-63.  250 
nicchaiiical    |)roblems    of,    270 
mortality  and  results   of,  245- 

265,    270 
of    prolonged    sojourn,    indica- 
tions  for,   299 
malignant  growths  of  trachea, 

442-443 
removal   of  secretions,  484 
tacks  from  bronchus.  209 
unsuccessful   cases   of,   318-327 
hemiiilcgia   during,   262 
in  iliilclrcu,   172 
indications  for,  465 
in  diseases  of  trachea  and  lironrlil. 
46.5-488 
tuberculosis  of  tracheobronchi- 
al tree,   485-486 
oral,  anesthesia  in,  56,  60,  61,  62 

schema   illustrating,   156 
position  for,  77,  78-80,  82,  83-86 
reactions    following,   general,   261- 
262 
local,  262 
secretions    during,    63 
trachootomic.  56,   171,   2.55-258,  326 
versus  oral,  164,  255 


Bronchotracheal      inflammations      and 

their  sequelae,  476 
Bronchus,    abscess    in    right    inferior 
lobe,  230 
anterior    branching,    entrance    ot 

170 
branch,  entrance  of,  170 
entrance      of,      with      slanted-end 

bronchoscope,    169 
diverticulum  in  left,  complicating 

tuberculosis,  486 
left,  entrance  of,  169 
middle   lobe,   entrance  of,   170 
protector,  Briinings',  275 
right,  entrance  of,  169 
stenosis  of,  248 

upper  lobe,  entrance  of,  171,  172 
exploration   of.   467 
Cadaver  for  study  of  anatomy,  use  ot, 
52,  202 

practice  on,  76,  203 
Caliper   guide   method  of  localization, 
Boyce,  author's  modification  of,  219, 
231     232 
Cancer,  infectiousness  of,  666 
of  esophagus,  444-449 

symptoms  of,  early,  446 
of  larynx,  647   (see  laryngeal  can- 
cer) 
resection  of  thoracic  esophagus  in, 
450 
Cancerous   stenosis   of   the   esophagus, 

529 
Cannula,  breaking  off  of,  in  situ,  608 
cane-shaped,  author's,  472,  474,  589 
cleansing   of,   608 
defective,  591 
emergency,  591 

for     various     ages,     tracheotomic, 
size  and  radius  of  curvature  of 
author's,  591 
full-curved,    gauze    used    to    hold 

out    long,   591 
llahn,  668 

laryngostomy,  author's.  628,  629 
T-shaped    separable    tracheal, 
628-629 
obstruction  of,  609 
snare,  heavy,  39,  40 
tampon,    66 
Trendelenberg,  668 
tracheotomy,  65,  589,  607 
valve,   IJe  Sanll,  590 
Carcinoma,   laryngeal,    107 

mesnthorium   treatment  of,  154 
of    epigloUis,     removal    of,    under 
siisiiension  laryngoscopy,  154 
Cardia.    hiatal    constriction    mistaken 

for,  191 
Cardiac   failure,  67,   74,  91 
Cardiospasm,  55,  505,  507,  510-521 
treatment   of,   519 


INDEX. 


Carina  as  an  aid  in  diagnosis,  respira- 
tory movement  of,  467 

identification  of,  166,  168,  169 

broncliial    orifices    in    disease 
of,  169 
position   of,   relative   to   long  axis 
of  trachea,  240 
Catheter,  insufflation,  66,  68,  69 
introduction  of,  71,  72 
silk-woven,   61,   63,   66 
Cervical  cellulitis  after  endolaryngeal 

operations,  118 
Chest,  physical  examination  of,  234 
Children,  holding  of,  for  examination, 

86-87 
Chloroform,  58,  59,  61,  63,  68,  125,  210 
and  morphine  in  bronchoscopy,  162 
effect  of,  on  color  of  bronchoscopic 

image,   175 
in    endoscopy    for    foreign   bodies, 
402 
esophagoscopy       for       foreign 

bodies,  339 
suspension     laryngoscopy     in 

children,   143 
thyrotomy,    663 
Cicatricial  stricture  of  esophagus,  site 

of,   525 
Circuits,  commercial,  28 
Clamps,  hemorrhage,   150.   152 
Closure  of  air-passages  to  food  during 

swallowing.  111 
Clubbed   fingers   in  foreign  bodv   case, 

314-315 
Cocain,  56,  57,  58,  60,  62,  63,  64,  72,  106 
126 
effect  of,  on  color  of  bronchoscopic 

image,  175,  478 
for     paralyzing     animal      foreign 
bodies  in  tracheobronchial  tree, 
293 
idiosyncrasy  to,   118 
in    suspension    laryngoscopy,    134, 
142,   143 
tracheotomy,   598 
rules  for  use  of,  57,  58 
Cocain-adrenalin  in  thyrotomy  662 
Codein,  63 

Coin   in  hypopharynx,  removal  of,   154 
Constriction,  cricopharyngeal,   188 
Constrictions  in   the  esophagus,  52 
Cord,   accidental   removal  of  posterior 
half  of,  105 

necessity  of,  for  proper  phonation, 
114 
Cords,    adventitious    vocal,   endolaryn- 
geal    operations     favoring    develop- 
ment of,  112,  429 

exjjosure  of  vocal,  98 
growths  on   vocal,   89,  93 
vocal.  94,  236 


Cords,  vocal,  nodules  on,   151,   420 

plionation  for  identification  of,  in 

direct  laryngoscopy,  123 
polypus  of,  154 
Cough  as  symptom  of  foreign  body  in 
esophagus,    332 

croupy,  in  children,  92 
tracheoesophageal  wall  during,  en- 
doscopic view   showing  forward 
bulging      of      posterior      mem- 
branous,  177 
Cough-reflex,   abolition   of,   54,    56,   58, 
68,  72,   78 
absence  of,  in  influenzal  tracheitis, 

482, 
preservation  of,  308,  636 
Counter-pressor   for   suspension    laryn- 
goscopy, 141 

Killian,      for      suspension      laryn- 
goscopy, 141 
Crayons      for     sketching      endoscopic 

image,   204 
Cricoarytenoid  joint,  injury  to,   196 
Cricoid  cartilage,  188,  192 
Crieoi)haryngeal    fold,    186 

spasmodic   stenosis,   508-510 
Cricopharyngeus,  difficulty  of  passing, 
188 
spasmodic   constriction  of,  561 
spasm  of,  secondary  to  gastric  dis- 
ease. 506 
Cricothyroidotomy,  593,  602 
Cup     for     anesthetic     solutions,     Yan- 

kauer's,  41 
Curette,  double,  149,  152 

reversible,    148,   152 
Cyanosis,  64,   118 
Death-space   of   Meltzer,   67 
Decannulation,  113,  610 

after  cure    of    laryngeal    stenosis, 

645-646 
difficult,  in  laryngeal  stenosis,  612- 
621 
Dental    protector,    Mosher's    laryngeal 

spatula  with,  19 
Diagnosis,  taking  a  laryngeal  specimen 

for,   107 
Diathermy  in  treatment  of  inoperable 

malignancy,  441 
Difficulties  in  direct  laryngoscopy,  100 
Dilatation  in  stenosis  of  esophagus,  531 
of  chronic   laryngeal  stenoses,    in- 
tubational,  622-627 
Dilator,   esophageal,   Jlosher's,  42 

for     bronchoscopic     dilatation     of 
bronchial  stricture,  41,  302, 
308 
endoscopic    use    in    bronchial 
and  esophageal  stricture,  41, 
44,  533 
Trousseau.   599,   604,   609 
Diphtheria,  anesthesia  in,  126 


INDKX. 


Uiplitheria.  iiiftuenzal,  laryngo-trachei- 
tis,  simulating,  481 

laryngeal,  foi'eign  body  diagnosed 

as,  266-267 
subglottic  edema  in  children  after, 
115 
hyperplasia   in   chiklrcn   after, 
115 
cases,   cannula   in,  obstruction   of, 
609 
Direct     laryngoscopy     (see     laryngos- 
copy ) 
Disease  high  up  in  esophagus,  26 
Distal   illumination.   M,  15,   IG,  23,  24, 

27,  28 
Distance,   estimation   of,   201,   203,   272 
273 

Diverticulum   due  to  cicatricial  steno- 
sis, 52!t 

esophageal,    53,    540-556 
of  esophagus,  after-care   following 
operation  for,  556 
pressure,    542 
pulsion,   541-556 

diagnosis  of,   545 
etiology  of,  541 
filled    with    bismuth    mix- 
ture, 544,  545 
prognosis  of,   543 
recurrence    of,    549 
symptoms  of,  544 
treatment  of.  550 
suspected,     esophagoscopy     in 

cases  of,  546 
traction,  540 
of  Zenker,  pulsion.   ISO 

Divulsor,  41,  308 

expanded  in  living  patient,  520 
for  treatment  of  esophageal  sten- 
osis, 533 
Dog,   practice  on,    203 
Dosimetric     anesthetizing    attachment 
for  bronclioscope.  Buchanan's,  22,  59. 
68 
Drainage     canal,     .lulhor's     esophago- 
scope  and  gastroscope  with,  24,  78 
tube,  74,  77 
Drowning    of    patient    in    his    own   se- 
cretions, 482-484 
Dysphagia,   1 1 1 

following  esophagoscopy,  195 

Dyspnea,  56,  59,  62,  67,  77,  92,  109,  112, 
115,  125,  126,  128,  161,  185 
as   symptom  of   foreign   bodies  In 

esophagus,  332 
bronchoscopy  in,  249,  465,  5S6 
due     to     foreign    body    in    larynx, 

traclieotomy  for.  267 
lns|iiralory.  without  laryngeal  ob- 
struction. 481 


Dyspnea,     laryngeal,     following    endo- 
laryngeal   operation.  117.   118 
sudden  death  in,  factors  in,  585 
suspension    laryngoscopy    in    pres- 
ence of,   149 
Echinococcus  of  lung.  433 
Kdema,   angioneurotic,  488 

annular,  283,  284.  287.  290 
esophageal,  angioneiirotic.  5(;5 
laryngeal,  22,  .53,  108,  118,  263,  580 
in  suspension   laryngoscopy.  153 
subglottic,   102,   115.  116,   130,   160, 
460 
cause  of,  during  bronchosco))y, 

263 
due  to  pressure  on  larynx  dur- 
ing bronchoscopy,  163,  257 
in   children,  172 
post-diphtheritic,  622 
tracheotomy  in,  593 
treatment  of,  2(55 
supraglottic  laryngeal,  262 
tracheal,    invisibility    of    ring    in, 
177 
Electrode    for     galvano-cauterizations, 

42,  117 
Electrolysis  in  esophageal  stenosis,  537 
Emetics  in  foreign   body  work,  338 
Emphysema  in  foreign  body  cases,  299 
of    neck    following    endolaryngeal 
operation.  1  IS 
Enchondroraa  of  tracheobronchial  tree, 

432 
F^ndobronchial    treatment,    467 
Endolaryngeal     extirpation     of     papil- 
lomata  of  larynx,  425 
operations.  20 

after-care    following,   117 

during.   118 
complications  during.  118 
danger  signs  following,  118 
favoring    development    of    ad- 
ventitious  vocal   cords,   112- 
114 
Endoscopic    appearances     in     tracheo- 
broncliial  tree  and  esophagus,  varia- 
tions of,  52 

of  benign  growths  in  tracheobron- 
chial tree.  434 

child's  larynx,   128 
esophageal   jiaralysis,   560 
foreign    bodies    in    esophagus, 

341 
laryngeal   disease,    460 
evisceration  of   larynx  for   cicatri- 
cial stenosis.  1 13 
excision    in    unsuccessful   cases   of 
bronchosco|)y  for  foreign  bodies, 
318 
foreign  body  extraction,  rules  for, 

293 
image     obtained     by     suiiraglottic 
tracheoscopy.    131 


■VI 


INDEX. 


Endoscopic    use  of   laryngeal    forceps, 
103 

view  at  end  of  second  stage  of  di- 
rect laryngoscopy,  123 
Endoscopy    for    foreign    bodies    in   air 
and  food  passages,  illustrative  cases 
of,  402-419 

in  children,   58 

malignant    disease    of    larynx, 
437-441 
instructions  to  patients  for,  95-96 
mechanical     ingenuity     necessary 

for,  26 
peroral,   anesthesia   for,   54-62 
position  of  patient  for,  77-88 
removal  of  secretions  in,  29 
shock  after,   261-262 
Enteroclysis,  53 

Epiglottis,  91,  92,  94,  96,  98,  99,  236 
amputation    of,    for    palliation    of 
dysphagia,  111 
in   tuberculosis,   112,   462 
carcinoma   of,   removal   of,   154 
cause  of  failure  to  expose,  124 
downward  traction  of,  96,  98,  99 
elevation  of,  121 
exposure  of,  121 
identiflfation  of,  69,  96,  97,  99,  101, 

121 
malignant  disease  of,  438 
Reichert  hook  for  raising,  140,  144 
of    children    as    seen    with    direct 
laryngoscope,  128-130 
Epiglottis-spatula,  use  of,  145 
Esophageal     diverticulum,     recurrence 
of,  549 

function   after    prolonged    sojourn 

of  foreign  bodies,  335 
mucosa,  192 
occlusion    in    foreign    body    cases, 

author's  symptoms  of,  332 
rejjair  after  laryngectomy,  plastic, 

672 
resection,  673 
spasmodic  stenosis,  age   as  factor 

in,  507 
stenosis,  pvriform  sinuses  in,  491, 

500 
wall,  weak  point  in,  186 
Esophagismus,  55 

abdominal,  514,  515 

nerve-cell  habit  as  a  factor  in. 
506 
hiatal,  510-521 

diagnosis  of,  517 

simulating   diverticulum,    516- 

519 
treatment  of,  519 
in  now-born,  507 
Esophagitis,  acute,  362,  495 
chronic,  499,  523 

treatment  of,  499 


Esophagites,  from  blind  efforts  to  re- 
move foreign  body,  337-338,  362 
Esophagoscope,    19,   21,   23.   24,    25,   26. 
30,  74 

anchoring  of,  187 
angular,  13,  14 
author's,  24 

Briinings',  introduction  of,   197 
Einhorn,  19 

for     esophageal     diverticula,     au- 
thor's, 546 
Guisez,   15 
Hill,   18 

introduction  of,   55,  88,  178-198 
by  sight,  187 
patient  recumbent,  187 
stages  in,   1S7 
Kahler,   13 

technic  of  introducing,  197 
light-carrier  during  withdrawal  of, 

194 
Mosher.  13,  14 
reinsertion  of,   194 
sizes  of  author's.  342 
slanted-end,   author's,  189 

position  of.   in   recumbent   pa- 
tient,  188 
Esophagoscopic  aid   in   excision  of  di- 
verticulum, 551 

appearances   and   diagnosis   of   ci- 
catricial   stricture,    527 
malignant    disease    of    esoph- 
agus, 446 
appearances    in    esophageal    lues, 
562 
tuberculosis,  564 
appearances  of  spasmodic  stenosis 

at  cricopharyngeus,  509 
extraction    of   foreign    bodies,    341 
image,    192 

removal    of    foreign     bodies,    me- 
chanical problems  of,  346-362 
views  in  cases  of  diverticulum,  547 
Esophagoscopy,  25,  28,  32,  53,  60,  78 
anesthesia  for,  55,  56,  58,  60,  61,  62, 

64,   180 
asiJirator  for,  29 
complications   following,   195 

precipitated   by,  197 
difficulties  of,  193,  200 
downward  escape  of  foreign   body 

in,    61 
fluoroscopic,  359 

for  determining  advisability  of  op- 
eration for  laryngeal  malig- 
nancy, 438 
esophageal    disease,    contrain- 
dications  in.   490-491 
technic  of,  492 
foreign   bodies.   339-362 

complications     and      dan- 
gers of,  360-362 


INDEX. 


Esophagoscopy   for   foreign    bodies    in 
cliildren,  61,  62 

instruments    for,    341 
mortality   of,   337,   339-340 
results  of,  339 
higli-Iow   method   of,   author's,   79, 

189-193 
in  cases  of  suspected  diverticulum. 
546 
diagnosis  of  esophageal  diver- 
ticulum, iJ46 
indications    and    contraindications 

for,  178 
in  esophageal  disease,   indications 
for.  489 
foreign    body    cases,    contrain- 
dications to,  340 
injuries  from  forcilile  unskilled  at- 
tempts at,  196 
in  new-born,  490,  492,  .'.07 

spasmodic      stenosis      of     the 

esophagus,   ."jO.'j 
suspected   foreign   body   cases, 

indications  for,  340 
suspension.  I."i4 
position  for,  77,  78,  80,  83-86 
pyriform   sinus  in,  author's  meth- 
od of  finding.  188 
retrograde,  in  esophageal  stenosis, 

537 
specular,  IS.") 

technic  of,   185 
Esophagotome,  string-cutting,  author's, 

43,  5.37 
Esophagotomy,    external,    for    removal 
of  foreign  body,  33.'.,  33 

internal,  in  esophageal  stenosis, 537 
Esophagus,  accidental  entrance  of,   in 
bronchosco|)y.   161 
actinomycosis  of,  566 
anomalies  of,  492-495 

treatment   of,   494 
artilicial   denture   in,   417 
l)allooning  of,  according  to   Mosh- 

er  method,   195 
cancer  of,  esophagoscopic  appear- 
ance of,  446 
cicatricial  stenoses  of  the,  26 
constri<'tioiis  in.  52 

cricopharyngeal,    179.   180 

dermal    fla|i    oi)eration    for    repair 

of,  673 
deviation  of,  566-567 
dilatation  of,  diffuse.  502 

treatment  of  ditfuse,  503 
direction   of.   182 
diseases  of,  489-567 
disease  of.  diagnosis  of,  489 

esojihagoscopy   in,  489-492 

indirect   examinations   in.   491 

symptoms  of,  490 
diverticulum  of.   540-556. 


Esophagus,  diverticulum  of,  after-care 
following  operation  for,  556 

diagnosis  of  pulsion,  545 
difficulty  in  excision  of,  552 
examination  of,  548 
pulsion,  541-556 
removed  by  Gaub  method,  5.53- 

555 
traction,  540 
use  of  bismuth  in,  546 
edema  of,  angioneurotic,  565 
imperforate,  492,   494 
imjjlantation  metastases  in,   445 
in  esophageal  cases,  emptying  of, 

53 
inflammation    and     ulceration    of, 
495-498 
treatment    of    acute   and    sub- 
acute,  498-499 
interventions  in,  151 
intubation  of,  for  stenosis,  539 
lues  of,  561 

treatment  of,  562 
malignant   disease   of,    444-459 
diagnosis  of,  444 
differential    diagnosis    in,    449 
removal   of  specimen    in,  444- 

445 
intubation  in,  450 
site  of,  444 
treatment  of,   449-459 
Mosher's  device  for  ballooning,  24 
narrowing   of   aortic,    181 
apertural,  181 
bronchial.   182 
distance   from  upper  teeth   of. 

182-184 
hiatal,  182 
normal,  178 
spasmodic,  178-1.82 
neoplasms  of,  benign,  436 
paralysis   of,  329,  557-561 
diagnosis  of,  560 
endoscopic      appearances      of, 

560 
etiology   of,    560 
motor,  559 
treatment    of,  561 
perforation    of.    in    foreign    body 

work,  361 
pliysiological   constrictions  of,   179 
relative  jiosition  of  trachea  and,  79 
rupture  and  trauma  of,  494-495 
sensation   in,   paralysis  of,  557-559 
spasm  of,  etiology  of,  505 

symptoms   of,   505 
speculum      for      oiiorations      upon 

upper  end  of  the,   25 
stenosis  of,  cicatricial,  522-539 

classification   of   impermeable, 

538 
compression,  499-503 


Vlll 


INDEX. 


Esophagus,     stenosis     of,     congenital, 
493,  494 

decomposition  of  food  in,  527 
eccentric,   witli   interstrictural 

sacculations,   533-536 
diet  in,  533-535 
differential   diagnosis   in,   528- 

530 
foreign  bodies  in,  356 
rest   in,   530 
spasmodic,   504-521 
stenotic  conditions  of,  26,  194 
strictures  of,   (see  stenosis) 
surgical  intolerance  of,   196 
thoracic,    190,    191 
tuberculosis   of,  563 

treatment  of,  565 
ulceration  of.  495 
ulcer  of,  differential  diagnosis  of, 

496-49S 
varix  and  angioma  of,  565 
webs   in,  494 

congenital,   26 
Ether,  58,  59,  62,  63,  64,  65,  67,  68,  210 
in    radiogi'aphic    work,    contrain- 
dications for,  222 
insufflation  in  thyrotomy,  661 
in  suspension  laryngoscopy  in  chil- 
dren, 143 
mucus.  68 
Ethylchlorid,  61 

Extractor,       screw-pointed,       Richard- 
son's,   40 
Extubal  method,  author's,   110-112 
Extubation.  624 

difficult,   115 
Eye,   education  of,   for   endoscopy,   44. 

201 
Fibroma  attached   to  under-surface  of 
right  cord,  104 

naso-pharyngeal,  anesthesia  in  re- 
moving, 67 
of  cord,   420 

primary   in   tracheobronchial  tree, 
432 
Films,   transparent,    author's,    321 
Finger  for  hyoid  bone  elevation,  64 
Fistula,    esophagotracheal,    congenital, 

493 
Fluoroscope,    double-plane,    Grier.   293. 

295,   577 
Fluoroscopic  esophagoscopy.  359 
Fluoroscopy  in  diagnosis  of  esophageal 

diseases,    489 
Food  debris  during  esophagoscopy,  79 
passage,  removal   of  foreign  body 
from,  88 
Forceps,  20 

alligator   punch.    37,    110-112,    269, 

346,  421 
author's,  32,  33,  34,  35 
bean.  Killian,  291 


Forceps,  Briinings,  36 
care  of,   49 
Casselberry,  36 

claw,  in  foreign  body  work,  291 
delicate,  necessity   for,   in  foreign 

body  work,   290 
dilating,  author's  41,   302 
faulty  models  of,  32-33,  35 
for   direct    laryngoscopy,  39 

esophagoscopic      removal      of 

open  safety  pins,  36,  351 
external  laryngeal  operations, 

author's   grasping,    635 
foreign  body  work,  32,  291 
infant    bronchoscopes,    35 
removing       animal        foreign 
bodies,   293 
in  endoscopic  foreign  body  extrac- 
tion, 272 
radium  treatment,  use  of,  456 
jaws  for  foreign  body  work,  34 
Killian's   "bean,"   32,   34 
laryngeal,  endoscopic,   use  of.   103 
lateral   movement    of.  by   author's 

method.    274 
Mathieu's,  32 

Mosher's  alligator,  26,  32,  269 
Paterson's,  32 

pin-cutting,      Casselberry's      endo- 
scopic, 36 
jiointed  jaws  for  author's,  36 
proper  closure  of,  34,  274 
rotation,  author's,   35,   36,  269-273, 

286,    347,    351,    353 
punch,  sliding,  37,  38 
Sajous,  laryngeal,  58 
side-curved  jaws   for  author's,   34, 

257,    277,   283,   302 
sliding  punch,  106,  107 
tissue,  36,  37,   106 
tube  versus  hinged-jaw,  32 
upper-lobe  bronchus,  author's,  293, 

294 
variety  of,  Heedlessness  of,  104 
Foreign  bodies,  anesthesia  for,  55,  58 
bechic  expulsion  of,  242 
beech    nut    hull    in    trachea    and 

bronchi,  483 
bismuth   capsules    for    localization 

of,    224-226 
blind    bouginage    in    presence    of, 

337 
bolus  of  meat  in  esophagus,  328 
bone  at  bifurcation,  388 
in   bronchus,   388 

esophagus.    386.    387.    389, 

415 
radiograph   of,  220 
hypopharynx,   390 
pharynx    and   entrance   to 

larynx,  148 
subglottic    region,    388 
trachea,  388 


INDEX. 


IX 


Foreign  bodies,  brass  fastener  in  right 
bronchus  for  seven  years,  304-306 
bronchoscopic   removal  of,   failure 
of.   246 
general      reaction      following, 

2.>9-261 
gravity  in,   290 
in    moderately    virulent   infec- 
tive     tracheobronchitis, 
260 
tracheotomized      patients, 
2.'):i-2.').S 
local  reaction  following,  262 
bronchoscopy     for,      contraindica- 
tions to,  248 
choice  of  time  for,  2.")0 
complications      and      after-ef- 
fects of,  2.-)8-26.5 
contraindications  to,  248-249 
duration   of,  250 
dyspnea  after,  262 
mechanical    jjroblenis    of,    270- 

296 
fluorosco|)ic,  295-296 
mortality   and   results  of,   245- 

246 
necessity    of    immediate,    249- 

250 
unsuccessful  cases  of,  318-327 
bullet  in  bronchial  orifice,  401 
buried    in    pharyngeal  and   esoph- 
ageal tissues,  357 
button   in  bronchus,  396,  397,  409 
esophagus,    397,    398,    414 
trachea,  ;196 
calcified  glands  interpreted  radio- 
graphically   as,   227 
cherry  stone  in  esophagus,  340,  394 
chinaware  in  larynx,  399 
classification    of,   in   air  and    food 

I)assages,  206 
coal   in  bronchus,  398 

removal   of,  290 
coin   below   plica  cricopliarvngeus. 
382 
in  esophagus,  227,  383-385,  414- 
415,   447 
and  trachea,  382 
hypopharynx,  382,  384 

removal  of,   154 
trachea,   382 
collar  button  in  esophagus.  331,  411 
left    bronchus    for    twenty-six 

years,  glass.  310 
lung,  312,  313 

right  bronchus  ten  years,  lead 
alloy,    305-309 
cough  and,  218 
coughing  up  of,  242-244 
cui'f  link  ulcerated  through  esopli- 
agus  into  trachea,  333-335 


Foreign  bodies,  denture  al    l)ottom  of 
hypopharynx,  399 

in  esophagus,  400 
determination  of  presence  of,  255, 

31  to 
diagnosis     of,     on     |)liysical     and 

laboratory   findings,  234 
digital  efforts  of  removing,  207 
dilatation  in  localization  of,  302 
diphtlieritic  membrane  in  trachea 

simulating.  247 
disk  in  esophagus,  386 
downward       escape       of,       during 

esophagoscopy,  330 
egg  shell  in  larynx,  394 
embedded,   278-279 
endoscoi)ic  extraction  of,  rules  for, 

293 
endoscopic  findings  in,  negative,254 
entering      lower      air      passages, 

gauntlet  to  be  run  by,  236 
eraser,  removal  of,  290 
esophagoscopy    for,    complications 

following,  195 
fish    hook    in    esojihagus,    removal 

of,  353-3.55 
fixed   crosswise   in   esophagus,   ex- 
traction of,  347 
flat  bone  in  subglottic  space,  148 
foot    of   alarm   clock   in   bronchus, 

411 
forceps  for  removal  of  irregular,  35 
fragments   of,   removal    of   broken 

off.   291 
gastroscopy  for,  576 
glass  in   subglottic  region,  395 
gourd    seed    in    bronchus,   395 
grasping   of.    for    removal,   276-277 
hardware   in   bronchus,  365-369 
esophagus,   hiatal,   368-369 
pyriform  sinus,  366 
trachea.  .369 
history  sheet   for.  214 
impacted.   5S 
in  adult,  dillicult  cases  of,  63 

air     and     food    passages,    88, 
206-235 
endoscopy  for,  illustrative 
cases  of,  402-417 
in  air  passages,  color  of,  251 

endoscopic  ai)pearances  of,  251 
etiology  of,  236 
symptoms  of,   215 
in   bronchi,    78,   81,    171,    209.    215. 
296,     304,     365-370,     372-373, 
379.   3SS,    393-401,    419 
expulsion  of,  242 
for  i)rolonged   periods,   297-:'.  17 
after-treatment     following 

removal  of,  303 
author's   cases  of,   304-317 


INDEX. 


Foreign  bodies  in  bronchi  for  pro- 
longed periods,  bronchoscopy  for, 
299-300 

cicatricial    tissue    due    to, 

303 
prognosis  of,  299 
stricture  due  to,  303 
symptoms  of,  224 
tight-fitting,    removal   of,    287- 

290 
voluntary  aspiration  of,  209 
in  bronchus,  large,  227 
left,  148 

middle  lobe,  241 
right,   148,  239-241 
upper   lobe,   293-295 
in  children,  preponderance  of,  237 
indurated  ulcer  at  carina  simulat- 
ing, 247 
in  esophagus,  61,  185.  209,  215,  218, 
226,     286,     328-338,     368-369, 
3i'0,    372,    378,    380-392,    394- 
400,   418,   447 
age   as   factor   in,   329 
fatality  of,  332-334 
lodgement  site  of,  329-330 
prognosis  of,  332,  335 
prolonged   sojourn  of,  357 
removal  of  broad,  sharp-point- 
ed, 349 
large,  355 
spasm   and  lodgement   of,  330 
strictured,   356 
symptoms  of,  216,  331 
treatment  of  cases  of,  335,  338 
in  food  passages,  removal  of,  88 
hypopharynx,  382,  384,  390,  399 
hysteric  and  insane,  208 
larynx,  92,   148,   209,   267,  374, 
380,  382,  388,  393-395,  399 
and  tracheobronchial  tree, 

236-265 
diagnosis   of,   266 
expulsion   of.   242 
removal  of,  55,  57,  78,   88, 

266-269 
symptoms  of,  216-266 
mouth,  78 
nasopharynx,  78 
pharynx,  removal  of,  78 
pleura,   401 
stomach,  208 
in   trachea,   56.   160,   209,   215,   216. 
234.  286,   369,  373.  379.  381,   382, 
388.  393.  396 

expulsion  of.  242 
in   traclieobroncliial  tree,   bronclio- 
scopic  finding  of.   252-254 
small  animal,  removal  of,  292 
soft    friable,   removal    of,    290- 
292 
into  pleura,  bursting  of,  310-314 


Foreign    bodies,   jewelrv   in   bronchus, 
370,  372,  373 

esophagus,  370,  372 
subglottic  region,  370 
"Job's  tear"  in  bronchus,  395 
lip  of  bronchoscope   for   disimpac- 

tion  of,  291 
localization  of,  222 
locket  in  esophagus,  416 
lose  of,  from  grasp  of  forceps,  303 
magnetic    extraction    of,    244 
maize  at  tracheal  bifurcation,  393 

in  bronchus.  393.  394-396 
meat  in  esophagus,  390-392 

removal  of,  356 
metallic,  238,  284 

capsule  in  right  bronchus,  148 
molar  tooth  in   bronchus,  226 
most   frequent  sites  of,  238-241 
multiplicity  of,  247 
nail   in  left  bronchus,  148,  314-318 
in   trachea  for   several   years, 
210 
nails,   removal  of,  276 
necessity  for  removal  of  secretion 

in    presence   of.    163 
needle,  extraction  of,  276 

in  the  intestine,  336 
nurse  in  presence  of,  necessity  of 

special,  258 
nut-hull  in  bronchus,  393 
olive  pulp  in   esophagus,  394 
overriding,   343-346 
paper  pulp  in  esophagus,  396 
pea  in  right  bronchus,  removal  of, 

292 

peanut    kernel    in    bronchus,    393, 

394-396 

most  fatal  of,  238,  261,  262 

pebble    in   bronchus,   398,   399,   410 

physical   examination  of  chest   in 

cases  of,  234 
pin  at  periphery  of  lung,  326 

in  posterior  branch  of  inferior 
lobe  bronchus,  323,  324 
pin  in  pyriform  sinus,  375 

right  lung  not  found  at  bron- 
choscopy, 322 

pins,  20,  299 

author's    method    of    exposing 

hidden,  253,  278 
extraction  of,  276,  277,  280 
in    air    passages,    position    of, 
239 

bronchi,  237,  264.  280,  326, 

373-379,  406,  408 
esophagus,  348,  378 
larynx,  374 

l)ins  in  trachea,  373 
pleuroscopy  for,  363 
plug  in  bronchus,  398 


INDKX. 


Foreign  bodies,  positive  film  of  tra- 
clieobronchial  tree  as  aid  to  localiza- 
tion of,  227-231 

primer  at  bottom  of  pleural  cavity, 

364 
prophylaxis  in,  207 
pyriform  sinus  as  biding  place  for, 

343 
radiographic    localization    of,    219- 

234,  304 
radiographs   of,   interpretation   of, 
226 
misleading    negative,    220-221, 
233 
radiography  of,  value  of  negative, 

231 
removal  of,  26,  78,   148,   199 

by     Briinings     esophagoscope, 

198 
by   esophagoscopy,  187 
ring  in  esophagus,  413 
rotation  in  removal  of,  269 
safety   pin   in  esophagus,  380,  381 

in  esophagus  of  infant,  354 
removal  of  open,  349,   332 

in   larynx,  380 
of  infant,  354 

of    child,    removal    of     piece     of, 
148 
in    pharynx    removed    by   sus- 
pension laryngoscopy,  148 
in    right    bronchus    of    infant 

of  3  montiis,  264 
in  subglottic  region,  379 
trachea,  379,  381 
of    infant,    228 
open,   56,    284 

lodged    point     upward    at 
bifurcation     of    trachea, 
286 
safety-pins,  open,  lodged  point  up- 
ward, endoscopic  closure  of,  286 
se<retion  in  presence  of,  234 
shell  primer  in  pleura,  401 
simulating     other     diseases,     247, 

267-268,  300,  311,  334,  338 
small,  downward   i)rogress  of,   229 

in  small  brondii,  231 
spontaneous  expulsion  of,  241 
staple  in  bronchus,  removal  of,  289 
in   esophagus,   412 
in  posterior  branch  of  inferior 

lobe   bronchus,   288 
in   right  lung.  289 
lodged   upward   in   esophagus,   353 
stenosis  due  to,  cicatricial  esopha- 
geal, 524 
suspected,  error  to  avoid  in,  235 
history  of  patient  and   deduc- 
tions  therefrom    in   case   of, 
1213 


Foreign  bodies,  suspected,  in  air  pas- 
sages or  esophagus,  necessity  of 
bronchoscopy  in,  232 

indications    for    bronchoscopy    in, 
246,  247 
indirect  examination  in,  217 
preliminary     examination     in 

cases  of,  267 
procedure  in  cases  of,  212-235 
symptoms,  after  aspiration  of,  213- 

216,  300 
tacks,  double-pointed,  in  bronchus, 
removal  of,  289 
extraction  of,  276,  280 
in  bronchus,  233,  284,  309,  403, 

405 
in  intestines.  212 
in    posterior    branch   of    right 
inferior   lobe  bronchus,   209- 
211,  213 
lodged   upward   in    esophagus. 

double-pointed,    353 
upholstery,  mushroom   anchor 
problem  of,  281-283 
with  buried  point,  extrac- 
tion of,  282 
thoracotomy  for  removal  of,  326 
through  glottis,  bringing,  274 
tooth   in  bronchus,  399,  400 
tooth-plate      in      esophagus,      jiro- 

longed  sojourn  of,  35 1,  35S 
tracheotomy  for,  584 
walnut  shell  in  esophagus,  394 
wandering  of,  through  esophageal 

wall,   255 
watermelon      seed     in      subglottic 
larynx,  393 
in  trachea,  393 
Foreign  body  work,   bronchus   in.  ru|)- 
ture  of.  280 

dog  for  practice  in,  203 
fluorescent  screen  in,  222-224 
forceps,  32 

gravitation    in,  necessity   for   con- 
sidering. 217 
Fulcrum  of  bronchoscopic   lever,   posi- 
tion of.  163,  265 
Fulguration  for  papillomala  of  larynx, 

424 
Gag,  use  of.  69 
mouth,    38 

in  bronchoscopy,  38,  162 
Gallows    for    suspension    laryngoscopy 

136 
Galvanocaustic    treatment     of     tuber- 
culosis, 116 
Galvanocauterization   for    chronic     hy- 
pertrophic  laryngeal  stenosis.   115 
of      post-diptlieritic      suligh)ltic 
stenosis,   effectiveness  of.    115 
Galvanocautery  puncture,   116 


xu 


INDEX. 


Galvanocaustic      deep      puncture      in 

suspension   laryngoscopy,   152 
Galvanopuncture    for   laryngeal    tuber- 
culosis, 462. 
Gangrene  of  lung.   484 

bronchoscopy  in,  248 
Gastric   mucosa,   193 
Gastroscope.   angular,   13 
author's,   24,  577 
Janeway,   577 
Gastroscopical    examination   of   a   gas- 
trojejunostomy  wound,    575 
Gastroscopy,  29,   568-578 
anesthesia  for,  -  58,   65 
cases   of,    574-575 
for  foreign  bodies,   576 
lens-system,   577 
mortality  of,  570 
open-tube,    577 
outlining  of  stomach  in,   571 
position  of  patient  for,  575 
technic   of,    570 

through     the     celiotomic     wound, 
577 
Gastrostomy     in     cases        of      water 
hunger,  491 

in  hiatal  esophagismus,  521 
in  malignant  disease  of  the  esoph- 
agus, 445,   450 
in  stenotic  esophageal  disease,  491, 
498 
Gauging    depth     by    use    of    one    eye 

only,  104 
Gauze   dressing    in   laryngostomy,    639 
Globus   hystericus,   508 
Glottic    chink,    188 

phonation    for     identification      of, 
in  direct  laryngoscopy,  123 
Glottis,  exposure  of,  98 

loss  of  foreign  body  at,  cause  of, 

274-275 
opening   of,   in   bronchoscopy,   162 
Goiter       as       cause       of      congenital 
tracheal   stenosis.   470-471 
dyspnea   of,   cane-shaped    cannula 

relieving,    590,    592 
operations,  examination  of 

larynx  previous  to,  91 
Gown   for  operator.  46 
Granulations,    removal    of.    301 
Granuloma.   421 

of   tracliea.   433 
Growths   hidden   by   overhang   of    the 
ventrioilar  band,  109 

in    larynx,   benign,  420-430 
in    ventricle    of   Morgani.    schema 
illu.strating  lateral  method  of  ex- 
posing. 110 
of    trachea,    malignant,    bronchos- 
copy in,  442-443 
springing     from     the     outermost 
depth    of     the     right     ventricle, 
109 


Growths,   laryngeal    indirect   views   of 
different  types  of,  104 
on  cords,  89 
primary   in   tracheobronchial  tree, 

benign,   431-435 
removal       of,       from       laryngeal 

ventricle,  109 
sessile,  removal  of,  110 
subglottic,  removal  of.  131 
vascular,  60 
Guillotine,  Katzenstein,  420 
Handle,  author's  universal,  33,  41 
Handles     tor     laryngoscopes,     bronch- 
scopes,    and    esophagoscopes,    Briin- 
ings'  two  illuminating.  13,  14 
Head,    during    bronchoscopy,    position 
of,   241,  257 

position  of,  in  direct  laryngoscopy, 

101 
in  peroral  endoscopy,  85,  88 
supporting-apparatus        for,        at- 
tached to  suspension  appliance, 
135 
Head-cover,  46 
Headlamp,   Klrkstein,  12,   27,  28, 

Kirstein,     Killian's     use     of     142, 
143.    145,   202,    264 
Headlight.   Claar,  15 

as  used  bv  Guisez,  202 
Phillip,   16,  17.   21 
Hemicricoarytenoidectomy     in    malig- 
nant disease  of  larynx,  652 
Hemilaryngectomy   for  malignant  dis- 
ease of  larynx,  652 
Hemophilia,  53,  118 
Hemoptysis,     bronchoscopy     in,     466, 
486 

causes   of   487 
due  to  luetic  lesions,   485 
Homorrhage,  laryngeal,  in  homophiles, 
118 
tuberculous      pulmonary       during 
bronchoscopy,  262 
clamps,   150,  152 
Hemostat,    58 
Heroin,  57 

Hiatus,    constricting    musculature    at, 
drawing    of    under-surface     of     dia- 
phragm showing.  512 
Hiatal    constricture.    identification    of. 
191 
esophagismus,    510-521 
Hiatus,  passing  the,  190,  192,  193 
Hook,  curved,  full  278,   286 
Killian  40 
Lister,   40,  272 

Reichert.      for      pulling      forward 

base  of  tongue  and   larynx,   143 

Reichert,     for     raising    epiglottis, 

140,  144 

Hooks,  272 

Hot-air-chest,  Albrecht,  for  edema,  153 


INDUX. 


iJydrogen      peroxide     after     interven- 
tions in  laryngeal  tuberculosis,    154 
Hyoid    bone,    antagonism    of    muscles 
attached  to,   72 

downward    traction   of   tissues   at- 
tached   to,    96,   98,   99 
elevation,   64,    69,   71,   124 
elevation    of    tissues    attached    to, 
121 
Hyperplasia.        subglottic.        following 

diphtheria.    11.5 
Hvperthymization    of    bleed     91,     473, 

475 
Hypodernioclysis,  o'S 
Hypoiiliaryngeal    wall,    mucosa     from. 

fAOUgiiig  of.   196 
Hypopharyngoscopy,  90,  181 
Hypopharynx.    exposure   of.    181 

livpopharvngoscopv    for    studv    of. 
9(1,   181 
Hysteria,  anesthesia  in.  56 
Hysteric,  foreign  bodies  in  the,  208 
Illuminating  devices,   11,  16 
Illumination,   defective,   202 

distal   versus  proximal,  264 
for    suspension    laryngoscopy,    142 
Image,   bronchoscopic,   normal,   175 
endoscopic,     92-95,     99,     118,     131, 

176,  192.  341 
sketching    the.    204 
Indirect    views    of    different   types     of 

laryngeal  growths,  104 
Infiltrations,     diffuse     laryngeal,     107- 
108 

direct   laryngoscopy   in    treatment 
of  ulcerative   and   nonulcerated. 
117 
Influenzal    tracheitis,    480-482.    484 
Insane,  foreign  bodies  in  the,  208 
Instructions  to  patients  in  endoscopy, 

95-96 
Instrumentarium,    portable.    29 
Instruments,  author's,  16,  202 
Briinings,   102,  201,   202 
care  of.  4S-.".l 
for   bronchoscopy.   85 
diagnostic   direct   laryngoscopy    in 

children.   126 
endoscopy    arrangements    of     44. 
49 

necessary,  47 
for  esophagoscopy,  85 
for     removal     of     papillomala     in 

larynx,  127 
for    suspension    laryngoscopy,    13."i 
Kahlcr's.  102.  201 
iiKiti-rial    for   manufacture   of.    11 
modilicalions   of.    11 
sterilization    of   47 
Insufflation.  .".9,  60,  61,  62.  64.  65 
apparatus,   Braun.   143 
bronchoscopic    oxygen.    73-76 


Insufflation,   ether.  38 

anesthesia,  Klsberg  apparatus  for, 
61.  64,  73 
Intercricothyroidotomy,   592 
Intratracheal    insufflation    anesthesia, 
65,   66-68,   73,   75,   320,   669 

tubes,  technic  of  insertion  of,   68 
oxygen  insufflation,  75 
laryngeal   stenosis,   622-627 
treatment     of     chronic     laryngeal 
stenosis,     care    of    patients 
under,  624 
duration  of,  627 
vocal  results  of,  627 
Introducer  for  author's    self-retaining 
intubation  tubes,  626 
Mosher,  626 
Intubation  and  extubation,  624 

in  acute  laryngeal  stenosis,  583 
of   esophagus    for    stenosis,    539 
of  esophagus  in  malignant  disease, 

450 
tracheal,  75 
tubes  and  instruments,   622 

care  of,  625 
tube  for  chronic  laryngeal  stenosis, 
self-retaining,  author's,   625,  626 
tubes      and       chronic       laryngeal 

stenosis,  sizes  of,  625 
tubes,     esophageal,    Charters     Sy- 

monds,'  451-452 
tubes,  self-retaining,  Schmiegelow, 

624 
and  extubation,  624 
Intubational     dilatation      of     chronic 
laryngeal  stenosis,  622-627 

treatment     of     chronic     laryngeal 
stenosis,    care     of    patients 
under,   624 
duration  of,   627 
vocal    results   of.    627 
Iodine    after    interventions     in     laryn- 
geal   tuberculosis.    154 

.laws  lor  author's  forceps,  side-curved, 

34 
Knife,  galvanocautery,   115 

laryngeal,  author's,  112 
Laboratory  examinations  ot  secretions, 

16 
Lactic'     acid     after     intervention     for 

laryngeal  tuberculosis,  154 
Lamps,  bronchosco|)ic,  22,  23,   201 
Uriinings,  cleansing  of,  28 
cleansing  of,  23 
cold,   21 

sterilization  of,  47 
Laryngeal  acromegalic  stenosis,  trache- 
otomy in,  587 
cancer,    operation     for,    mortality 
and   results  of,  652 


XIV 


INDEX. 


Laryngeal,  palliative  treatment  in,  647 
prophylactic  treatment  in,  467 
recurrence  in,   655 
site  of,  651 
statistics  in,  657 
complications    of     typhoid     fever, 

618 
disease,  endoscopic  appearances  of, 

460 
exposure    tor    intratracheal    insuf- 
flation, 75 
exposure,   left-handed.   103 
exposure,  prolonged,  103 

laryngectomy     for,     mortality 

in,  656 
malignancy,  excision  of,  665 
operation  tor,  choice  of,  650 

contraindications    to,    649 
statistics  in,  657 
mirror     in     suspension    laryngos- 
copy, 153 
Killian  method  of  using,  90-91 
operation,    direct,    preparation    of 
patient  for,  103 
technic   of,  103-107 
orifice  and  swallowing,   236 
papillomata  (see  papillomata) 

in  children,  149-151 
paralysis,  205,  501 
paralytic    stenosis,    bilateral,    613- 
614 
monolateral,  614 
reflex,  60 
sarcoma,  439-440 
specimen  for  diagnosis,  obtaining, 

107 
stenosis,  acute,  surgical  treatment 
of,  583 
ankylotic,  615 
acromegalic,    tracheotomy    in, 

587 
chronic,  dilatation   of,   622-627 
preventing   decannulation, 
types  of,  612-621 
cicatricial,     laryngostomv     in, 
631 
post-diphtheritic,   618 
complicating     typhoid     fever, 

acute,  580 
decannulation    after    cure    of, 
645-646 
cork    for    occluding    can- 
nula before,  646 
dilatation   of,   Thosfs   appara- 
tus for,  632 
diphtheritic,  617 
due    to    perichondritis,    acute, 

in  infants,  583 
in  new-born,  582 
intubation  treatment  for,  care 

of  patients   under,  624 
luetic,  617 


Laryngeal  stenosis,  neoplastic.  615 
panic,  612 

papillomatous.  615,  631 
paralytic,  cordectomy  in,  613 

treatment  of,  614 
post-tracheotomic,  593 
scarlatinal,  619 
schema    of   problem    in,    after 

wearing  of  cannula,  630 
scleromatous,   617 
spasmodic,   613 

treatment  of,  613 
suicide  and,  620 
tonsil  in.  removal  of,  599 
traumatic,  619 
tuberculous,  616 
typhoid,  618 
stridor,  congenital,  130,  462-464 
surgery,  579-583 
tumors    above    cords,    removal    of 

benign,  110 
web  in  child  simulating  neoplasm, 
congenital.  129 
Laryngectomy,  66 

after-care  following,  672 
anesthesia  in,  669 
complications  of,  673 
contraindications  to,  672 
death  in,  causes  of,  653 
for    malignant    disease   of   larynx, 
indications  for,  652 
mortality  in,  656 
glands  during,  removal  of,  672 
position  of  patient  for,  669 
preparation  of  patient  for,  669 
sphygomomanometric  tracings  dur- 
ing, 653-654 
stitching  of  trachea  to  skin  in,  659 
technic    of,   669-673 
operative,  669 
total,  operative  mortality  of.  653 
tracheotomy  preliminary  to,  671 
with      intratracheal      insufflation 
anesthesia,  schema  of,  670 
Laryngopharynx,    familiarity   with    lo- 
cation of,  essential  to  esophagoscopy, 
205 
Laryngoptosis,  tracheotomy  in  case  of, 
594 

with  deviation  of  trachea,  468-470 
Laryngoscope,   author's   direct,   16,   20, 
21 

cleansing  of,  100 

during     direct     laryngoscopy, 
107 
Dickenson's.  19 
direct  for  hyoid  bone  elevation,  64 

stages  in  introduction  of,  121 
Hill's  modification  of  Jackson,   IS 
introduction   of,    58,    76,   92,  96-98, 

101 
L-shaped,  102 


INDEX. 


XV 


Laryngoscope,  narrow  lube,  102 
oval    lumen,    17,    19,    20 
regular,   for  introduction   of   bron- 

<hos<'ope,  157 
round   lumen,  17,   20 
side-opening,  72 
side-slide,  110 
subglottic,  25,  26 
Laryngoscopes,  16,  19,  20,  25,  26,  75 

direct,  90,  95 
Laryngoscopic    tube,    introduction    of, 

by  Briinings'  method,  17;i 
Laryngoscopic   views    in    children,    di- 
rect, 129.   130 
Laryngoscopy,  differenie  in  viewpoints 
in   direct   and   indirect,    S9-90 

direct,    52,    :,:!,    62,    72,    7S,    SI,    82, 
85,  86,  89-132 
anesthesia  for,  55,  59,  64 
by    lateral   and   oblique   meth- 
ods, 101 
contraindications  to,  92 
difficulties  of,   100,   123 
endoscopic  view  at  end  of  sec- 
ond  stage  of,   123 
for     the    removal    of    foreign 

liodieK,  266,  269 
in    adult    recumbent    patient, 

118-126 
in   children,  126,   128 

compared      to      that       in 

adults,   127 
difficulties  of,  127 
in  diseases  of  the  larynx,  460- 

464 
instruments      for      diagnostic, 

126 
instructions  to  patients  in,  95- 

96 
jiosition  for,  83,  84,  85 
rules   for,    100 
schema  illustrating  technic  of, 

122 
sijeculum  in,   20,  28 
view  at  end   of  first  stage  of, 
121 
indirect,  89-91 

with      the      Hays'     pharyngo- 
scope,  131 
post-anesthetic,  67 
subglottic,  102 

in  children,   130 
suspension,   126,    133-154 
anesthesia  for,  134,  142 
as     a     preliminary     step     to 
bronchoscopy      and      esoph- 
agoscopy,  147 
clinical   experiences  with,   146 
demonstration    in,   146 
examination      with      Kirsteln 
spatula   preliminary  to,  142 
for  diagnostic  purposes,  151 


Laryngoscopy,  suspension,  removal  ot 
foreign  bodies,   154 

treating     lower     pharvnx, 

154 
removal   of    metallic    cap- 
sule   from    right    bron- 
chus, 148 
removal    of    nail     lodged 
one   year    in    left    bron- 
chus, 148 
removal     of     nodules     on 

vocal  cords,  151 
removal     of     papillomata, 
151 
historical   data  on,  133 
in  adults,  152 

in  children,  therapeutic  appli- 
cation of,  148 
instruments  for,  135 
in  tonsillectomy,  151 
in  tuberculosis  of  larynx,  152 
origin  of,  133 

preparation  of  patient  for,  142 
removal      of      foreign      bodies 
under,  148 

Laryngostomy,    628-644 

after-care  following,   b,;9 

after-treatment        of,        Sargnon's 
method  of,  630 

ajiparatus  in  situ,   author's   radio- 
grapihc    view  of,   638 

author's  method  of,  schema  of,  630 

autopla^ity  after,  642 

lacing  adhesive  strips  for 
lessening  tension  on  sutures 
in,   644 

contraindications  to,  632 

definition   of,  628 

dilating  tube  and  dressing  in,  plac- 
ing of,  635-636 

epidermatization  in  author's  meth- 
od of  hastening.   6111-642 

for  laryngotracheal  stenosis,  643 
papillomata  ot  larynx,  427 

history  of,  <)28 

llowarth  method  of,  629,  631 

indications   for,  631 

incision   of   posterior   wall   in,   635 

in  post-typhoid  laryngeal  stenosis, 
results  in,  644 

instruments    for,    632 

one  month  after  0|)eration,  637 

prcliiiiiiKii'ies  for,  633 

prc|iaration  of  i)atient  for,  633 

result   in,  ideal,  641 

rubber  tube,  .Moure.  632 

steps   in,   634 

suture   of  mucosa  to  skin   in.   637 

treatment,   duration   of,   642 

wound    iuimediately   after,    636 

l.aryngotomy.  634 


XVI 


INDEX. 


Larynx,  anesthesia  in  paralysis  of,  64, 
72 
appearance  of,  in  direct  laryngos- 
copy by  the  oblique  method,  102 
artififial,  673 
bone   in   entrance  to,   removed  by 

suspension  laryngoscopy,  148 
cancer  of,  palliative  treatment  in, 
647 
prophylactic  treatment  in,  647 
child's,   endoscopic    appearance  of, 

128 
cocain   for   penciling,   143 
depth    of,    misconception    of    real, 

104,  105 
difficulty  of  finding,  100 
diseases    of,    direct    laryngoscopy 
in,  460-464 
tracheotomy  as  a  therapeutic 
measure  in,   584 
during   bronchoscopy,   position    of. 

163 
edema  of,  580 

endoscopic  evisceration  of,  for  ci- 
catricial   stenosis,    113 
examination  of,  for  diagnosis.   70, 
78,  92 
previous     to     anesthetization. 

91 
with  Hays  pharyngoscope,  132 
exposure  of,  70,  71,  72,  76,  82,  84, 
86.  88,  94,  96,  98-102.  106,  118 
difficulty  in,  163 
for  radium  application,  103 
recumbent  patient.  158 
stage  in.   121 
foreign   liody   in.   92 
granulation  tissue  in  the,  269 
granuloma  in,  420 
growths  in,  benign,  420-430 
inspection    of,    previous    to    inser- 
tion of  catheter  or  tubes,  68,  69, 
75 
in  typhoid  fever,  acute  stenosis  of, 

581 
malignant  disease  of,  647-660 
curative  operations  for,  649 
endoscopy  in,  437,  441,  649 
operation  in.  649 
thyrotomy  for,  661-668 
obstruction   in,  59,  75 
opening  of.   error  in,  635 
overflow  of  secretions  into,  79 
papillomata   of,  in   adults,  427-430 

in  children,  422-427 
paralysis  of,  91 

removal    of    foreign    bodies    from, 
55,  88 
growths   from,    78 
spasm   of,  99,   105,   128 
stenosis  of.  acute.  92,  580-583 
tuberculosis  of,  460 


Larynx,    tuberculous,    direct    view    in 
sitting  position  of  a,  116 
lesions  below,  117 
Left  hand,  advantages  of  holding  bron- 
choscope in,  166 
Left-handed    laryngeal    exposure,    103, 

121 
Leucoplakia,  an  early  stage  ot  esopha- 
geal  cancer,   448 
Light  carriers,  19,  21,  23 
Lights,  care  of,  51 
Lii)oma    in    hvpopharvnx,  removal  of, 

154 
Lip,  pinching   of,   between   instrument 

and  teeth.   101 
Ludwig's  angina,  foreign  bod.v  simulat- 
ing, 338 
Lues,  107,  108 

cancer  of  stomach  simulating,  448 
of  esophagus,   561 
of  tracheobronchial  tree,  485 
Lumen,    laryngeal,    68,   69,   93 
Lung,  gangrene  of,  484 

gangrene    of,    due    to    presence    of 
foreign  body,  320 
Malignancy,  esophageal.  193 
Malignant   diseases   of  larynx,   647-660 
Mandrin,  14,  15.  23,  24,  187,  197,  219 
in    exploring    esophagus    for    for- 
eign bodies,  342 
Mask   for  operator,  46 
Jlasks   in   artificial   respiration,   75 
Measuring  rule,   25 
Mediastinitis.     fatal     septic,     due     to 

faulty  esophagoscopy,  196 
Mesothorium    treatment    of    laryngeal 
carcinoma,  154 
to  prevent  rec\irrence  of  laryngeal 
papillomata,   149 
Morphin,  56,  63,  118 

in  suspension  laryngoscopy,  use  of, 
142.   152 
Morphin-scopolamin,    contraindications 

to  use  of,  143 
Nebulized   fluids   in   treatment   of  dis- 
ease,  inhalation   of,   467 
Neoplasms,  change  of  connective  tissue 
type  of.  to  epithelial  type,  439-441 
esophageal,  benign,   436 
laryngeal,  62 
Nephritis,     preparation    of,    for    endo- 

laryngeal   operation,  53 
Nodules  on  vocal  cords,  151,  420 
Nozzle  for  aspirator  for   removing   se- 
cretions from  fauces  and  pharynx,  29 
Xurse,    tracheal,    after    endolaryngeai 

operation,  117 
Obturators.  24 
Operating  room,  43 
organization,  579 


INDEX. 


XVll 


Oiiiuni   dirivalives,  loxio   effect  of,   62, 

125 
Orientation  in  direct  laryngoscopy,  101 
Oropharynx,  interventions  in.  1.")1 
Ortlioform  in  bronchial  asthma,  ITlt 
Osteomata   of   trachea,   4oo 
Oxygen,   jti.  'i'.).  To,  7t,  T-J 

insufflation,  branch  tube  for  bron- 

choscopic,  22 
tank,  4."),  50 
Packing     of     tracheal     and     external 
laryngeal    wounds,   author's   method 
of,  "639 
Panelectroscope,   Kahler's,    17 
Papilloma,  55,  57,  58,  59,  62,  87,  92,  9:i, 
112 

laryngeal,   congenital,  422 
Papillomata,  fibro-,  multiple  infraglot- 
tic,  104 

foreign  bodies  mistaken  for,  267 
in    children,    author's    method    of 
treating,  426 

treatment   of,   422-427 
in     hyi)o-|)liarynx    and    esophageal 

entrance,  removal  of,  151 
larvngeal,  in  adults,  427-4:50 

in  children.  149-151,  422-427 
instruments    tor    removal    of, 

127 
suspension     laryngoscopy     for 
removal  of,  151 
multiple,    104 
of  the  larynx  in  adults,  stuliljoin 

case  of,  104,  428 
primary  in  trachea,  431 
recurrence  of.    149 
removal  of,  depth  of,  427 
stenoses   due   to,  631 
subglottic.    130 
tracheal.  609 
Paralysis,  esophageal,  557-561 
laryngeal,  205,  501 

nerve-division  in  l)iUitcral,  t')l3 
posticus,    113,   196 
recurrent,  196,  466 
Perichondritis      in      infants,      stenotic 
laryngeal.  5S3 

laryngeal,     tracheotomy     in     post- 
tyiilioid,  599 
Peroral  endoscopy,  position  of  patient 
for.  77-88 

preparation  of  patient  for,  53 
Personal    e(iuati()n    in    clioice   of   anes- 
thesia,  54 
Pharyngotomy,     subhyoid,     for    malig- 
nant  disease  of  larynx,  652 
Pharyngosco|)e,  Hays,  for  examination 
of    larynx,    132 

indirect      laryngoscopy      witli. 
131 
Pharynx,  bone  in,  removed  by  suspen- 
sion  laryngoscopy,  148 


Pharynx,    safety    pin    in,    removed   by 
suspension  laryngoscopy,   148 

suspension  laryngos<-oiiy   for  treat- 
ing lower,  154 
Phonation.  114 

continuous,    for    identification    of 
glottic    chink    and   vocal    cords, 
123 
Phrenospasm,  510-521 
Pin-closer,  285,  286 

Plastic     operation     favoring     develop- 
ment   of    adventitious    vocal    bands. 
429-430 
Pleura,   perforation    of,    due    to    faulty 

esophagoscopy,   1 96 
Pleurisy,  foreign  body  simulating,  300 
Pleuroscope,  25 

Pleuroscopy  for  ideural  diseases,  364 
for  removal  of  foreign  bodies,  321, 
363 
Pneumonia,   bronchoscopy   during,   248 
Pneumonitis    following    aspiration    of 

foreign   body,  299,  311 
Pneumothorax,  bronchi  in,  487 

displacement     of      foreign      body 
after,  325 
Polypi    in    tracheobronchial    tree,    ede- 
matous,  435 
Polypus,   removal  of,  demonstrated  by 
suspension  laryngoscopy,  146,  154 
of  vocal   cords,   154 
Position,  Bovce.  70,  83,  84,  S6,  119,  157. 
164,  188,  326 
advantages  of.   for  esophagoscopy, 
190 
wide  range  of,   258 
elbow-rest,  author's,  70,  125 
extended,  70,   71,  79-81 
Hexed,   85 
for   bronchoscopy,  83 

direct   laryngoscopy,  82,  83 

author's,   82 
esophagoscopy,  83 

author's  "high-low,"  79 
.lohnston,  85,  86 
Kirstein.  79,  81,   82 
Mouret,  82,  83 

of   adult   patient   for   direct    laryn- 
goscoi)y.   sitting.   SI,   84 
assistant  for  bronchoscopy,  167 
for  direct  laryngoscoi)y,  82,  84 
cervical   si>ine    for   eso|)bagos- 
copy  and  bronchoscopy,  cor- 
rect, 80,  81 
infant    or   small   child    during 

direct    laryngoscopy,    128 
operator,  for  artilicial  respira- 
tion, 74 
for     direct     laryngoscopy, 
82,  84,  9G,  97 


-Will 


INDEX. 


Position  of  patient  and  assistants  for 
tracheotomy  and  for  artificial  res- 
piration, 595 

patient   for   bronchoscopy,   86, 
155,  466 
for  esophagoscopy.  86,  492 
for  insufflation  anesthesia, 

69,  70 
for  gastroscopy,  575 
for  laryngectomy,    669 
for   laryngostomy,   633 
for  peroral  endoscopy,  77- 

88 
for  radium  applications  to 
esophagus,   456 
table  for  suspension  laryngos- 
copy, 135-137 
recumbent,  83-88,  115,  118,  122, 

127.  157 
dorsally,  183 

for   bronchoscopy  in   children, 
172 
removal  of  foreign  bodies, 

235 
specular       esophagoscopy, 
185 
lateral,  164 

sitting  or  laterally,  184 
ventral,  for  introducing  bron- 
choscope, 174 
Rose.  79.  SO,  119,  202 

in   l)ronchoscopy,  264 

esophagoscopy,  181,   190 
Positions,    general    principles    for    all, 

79 
Position,   sitting,   88,   92,   96.   101,    102, 
116,   127,   155 
Trendelenberg,  66,  78 

during  tracheotomy,  287 
Potassium  iodid,   108 

and      mercury      in      compression 

stenosis  of  esophagus,   501 
to  prevent  recurrence  of  laryngeal 
papillomata,  149 
Practice,     thread,    with    bronchoscope 

and  forceps,  202 
Preparation  of  patient  for  i)eroral  en- 
doscopy, 53 
Probe    for    endoscopic    use,    eyed,    au- 
thor's, 43 
radiographic      localization,      lead- 
ended,  Briinings,  296 
Propaesin  in  bronchial  asthma,  479 
Proximal   illumination,  27 
Pulmonary  abscess,  bronchoscopy  dur- 
ing, 248,  476 
Pulmotor,  75 

Puncture,  galvanocautery,  116 
Pus,  removal   of,  before  bronchoscopy, 

301 
Pyopneumothorax  of  foreign  body  ori- 
gin, 311 


Pyriform    sinus,    accidental    exposure 
of,  100 

entering,  188 

familiarity    with    location    of,    es^ 

sential  to  esophagoscopy,  205 
finding  of,  88,   189 
in  esophageal  stenosis,  491,  500 
right,   188 
Radiography    in   diagnosis    of    esopha- 
geal diseases,  489 

in   diagnosis   of  esophageal   diver- 
ticulum. 545 
thoracic  disease,  301 
foreign    body    work,    209-212.    219- 

234,  301,  403-417 
negative,   value  of,   231 
Radium      application     to     cancer     of 
cardia,  peroral,  459 

capsule     in     center     of     annular 
esophageal      cancer,      sche- 
matic representation  of,  454 
situ     in    case     of    esophageal 
cancer,    457 
container  in  situ  in  case  of  esoph- 
ageal malignancy,  457-459 
for    malignant  disease   of  esopha- 
gus,  452-459 
author's  method  of  using,  454 
dosage  of,  456 
reaction  after,  458 

of  larynx,  439,   455 
for  papillomata  of  larynx,  424 
Ratchet,  14.   174 

Rectal  feeding  in  cases  of  water  hun- 
ger, 491 
Reflector,  Claar,  12 
Reflexes,  abolition  of,  94 

protective,   236 
Respiration,  arrested,  59,  60,  67,  74,  75, 
76 
artificial,    position   of  patient   and 

assistants  for,  595 
arrested,   tracheotomy   for,  584 
Roentgen  ray   treatment   of   laryngeal 
tuberculosis  in  suspension  laryngos- 
copy, 154 
Salicyl-alcohol    to    prevent    recurrence 

of  papillomata.  149 
Saliva  during  direct  laryngoscopy,  101 
Sarcoma,  esophageal,   449 

laryngeal,  107,  439-440,  651 
Scleroma,  suspension  laryngoscopy  in, 

154 
Scoijolamine    in    suspension    laryngos- 
copy, 142,  152 

Secretions,  71,  79 

age   on    removal    of,    influence   of, 

482 
drowning   of   patient   in   his  own, 

262,  280,  482-484 
during  esophagoscopy,  79 
laryngoscopy,    127 


INDEX. 


Secretions,  in  foreign  body  cases,  234 
lessening  of,  during  bronchoscopy, 

63,  78 
nozzle   for  attaching  to   aspirator 
for  freeing  fauces  and   pharynx 
from,  in  peroral  endoscopy,  29 
prevention     of,    overflowing    from 

pharynx  into  larynx,  30 
removal  of,   21,   23,   29,  30,  31,   77- 
7S,   483-484 
during  l)ronchoscopy,  4(56 
during  direct  !aryngoscoi)y,106 
in  esophagoscopy,  194 
prior  to  insertion  of  broncho- 
scoi)e,   1(13 
sponge-pumping     process     for    re- 
moval  of,  author's    (see  sponge- 
pumping  process) 
Yankauer's    method    of    removing, 
28 
Shield   for  gallows  to   prevent  patient 
coughing  in  oi)erator's  face,  147,  152 
Sinus,  pyriforni,  188 
Sketching  the  endoscopic  image,  204 
Skill,  acquiring  for  peroral  endoscopy, 

199-205 
Slide,  author's,  17,  18,  19 
Sliding  tubes,    Hriinings,    12,   17 
Snare,  bronchoscoiiic,   39,   4(1 

cannula,  heavy,  39,  40,  110,  112,  421 
eso|)hagoscopic,  39 
galvanocautery,   110 
tonsil,   Peter's,  39,  40 
Solutions    in    treatment    of    bronchial 

asthma,  479-480 
Spasm,  75,   70,  93,  94 

esophageal,  in  new-born,  507 

secondary  to  local  disease,  'MG 
hiatal,  overcoming  of,  194 
hypopharyng(^al,  liO 
laryngeal.      occluding       view       of 

larynx,   123 
of  esophageal  musculature,  fiO,  61, 
65 
inferior  constrictor,   65 
Spasmodic  contractions   in   esophagos- 
copy, 194 

stenosis    of    esophagus    at    crico- 
pharyngeal    level,   treatment  of, 
510 
Spatula,   Briinings,    14 

epiglottis,  use  of,  145 
Kirstein,  133,  142,  144 
tongue,    137,   140,   144 

introduction  of,  144 
with     dental     protector,     Mosher's 
laryngeal,  19 
Specimen  for  diagnosis,  laryngeal,  tak- 
ing a,  107 

malignant,  necessity  of  Immediate 
oi)eration  following  removal  of. 
108 


Spectacles,  40,  42,  46 
Speculum,  Boyce,  16 
Dickinson,  19 

esophageal,  anesthesia  for  use  of 
the,  65 
author's,  25,  26,  32,  64,  S8,  181, 

185,  492 
in   foreign  body  work,  344-346 
introduction  of,  186,  345 
use  of  child's  size  of,  for  sub- 
glottic laryngoscopy,  102 
exposure  of  larynx  with,  96 
Ingal's  open  laryngeal,  12 
introduction    of,    for    removal    of 

small  tumor  on  cords,   106 
author's    laryngeal,    16 
laryngeal,  15,  16,  20,  64,  69,  71, 
for  inspection  of  hypopharynx 
and     cricopharyngeal      con- 
striction, 185 
insertion  of,  71,  72 
Rendu,     for    gastroscopy     through 

celiotomic    wound,    577 
rotating,  laterally,  85 
sizes   of,    20,   26 
slide,  16 

tubular,  author's,  18 
use  of  lateral   opening,   102 
with    laryngoscope    handle,    John- 
ston's, 18 
Sphygomomanoraetric     tracings     dur- 
ing  laryngectomy,   653-654 
Spine,  position  in  diseases  of  cervical, 

85,  86 
Sponge-carrier,  author's,  30,  31 

Coolidge,  30 
Sponge-holder,  58 
Sponge-pum|)ing  process,  author's,   163, 

194,  262,  275,  291,  301,  304,  308 
Sponges,  23,  31,  32,  58 
bronchoscopic  32,  58 
endoscopic,  31,  32 
use   of,   during   bronchoscopy,   163 
Sponging  in  foreign  body  work,  342 
Spoon,  mechanical,  author's,  39,  292 
Status   lymphaticus,   473 
bronchoscopy  in,  248 
Spasmodic   stenosis  of  the  esophagus, 

504-521 
Stenosis    at    cricopnaryngeus,    esopha- 
goscopic  appearances   of   spasmodic. 
509 
abscesses  and,  620 
ankylotic,   post-ty|)hoid,   (!19 
bronchial,   cicatricial,   477 
cicatricial,  laryngoslomy   for,  631 
treatment  of,  621-627 
compression,  depth  of,  472 
esophageal,    496     ( see    stenosis    of 

esophagus) 
in   new-born,   laiyngeal,   582 


INDEX. 


Stenosis,  laryngeal,  ankylotic,  615 

decannulation    after    cure    of, 

645-646 
dilatation  of,  622-627 
diphtheritic,    617 
evisceration   of  larynx   for   ci- 
catricial, 113 
g  a  1  V  a  n  o  cauterization        for 

chronic,  115 
intubation  for,  624 
luetic,   617 
neoplastic.   615 
panic,   612 

papillomatous.   615,  631 
paralytic,  613 
removal  of  tonsils  in  patients 

with,   65 
scarlatinal,  619 
schema  of  problem  in,  630 
scleromatous,  617 
spasmodic,  613 
suicide  and,  620 
surgical    treatment    of    acute, 

583 
tuberculous,  616 
Stenoses,  laryngeal,  typhoid,  618 
of  esophagus,  cancerous,  528 
cicatricial,  522-539 
and  cancer,  529 
due  to  presence  of  foreign 

body,  524 
etiology  of,  522 
radiograph    showing   cure 

of  a,  534 
spasmodic     lesions     caus- 
ing, 523 
symptoms    of,    526 
treatment  of,  530 
compression,  499-503 
adenopathic,   501 
aneurysmal,  500 
aortic,  500 

carcinomatous   and   sarco- 
matous, 501 
differential    diagnosis    of, 

499 
goitrous,  500 
treatment  of,  501 

differential   diagnosis   in,   528- 

530 
luetic.  562 
spasmodic,  504-521 

due    to    aphthous    ulcera- 
tion, 496 
reflex  nature  of,  505 
of     larynx,     acute,     580-583      (see 
laryngeal  stenosis) 
and    trachea,    chronic,    612-621 
of  trachea,  compression,  615 

and  bronchi,  compression,  47u- 
476 


Stenoses,  treatment  of,  472 
post-diphtheritic,   113 

sub-glottic,     galvano-cauterlza- 
tion  of,   115 
preventing    decannulation,    hyper- 

lilastic   and  cicatricial,  616 
thymic  compression,  131,  472-476 
tracheotomic,  post,  593 
traumatic   cicatricial,  619 
Stimulants,  63,  74 

Stomach,  .vlosher's  device  for  balloon- 
ing the,  24 
Stools,  tor  operating,  85,  86,  96 
Strictures   (also  see  stenosis) 

anesthesia    in    after-treatment    of, 

56 
bougie    for,    author's    modification 

of  Guisez',  44 
bronchial,   dilator   for,   41 
author's.  44 
of  esophagus,  521 
cicatricial,  prognosis  of,  525 
congenital,   493,   494 
Stridor,    congenital    laryngeal,    462-464 
due   to   infantile    type    of    larynx, 

463 
serraticus,   609 
String      swallowing      in      esophageal 

stenosis,  537 
Styptics,    118 

Subglottic  hypertrophic   post-diphther- 
itic stenosis,  618 
papillomata,  130 

space,    flat    bone    In,    removed    by 
suspension  laryngoscopy,  148 
Suicide  and  stenosis,  attempted,  620 
Suiiraglottic      hypertrophic     post-diph- 
theritic stenosis,   61S 

tracheoscopy  and  subglottic  laryn- 
goscopy   in    children,   130 
Sus]jension-hook  for  suspension   laryn- 
goscopy, 136 

preparation  of,  144 
Suspension    laryngoscopy    (see    laryn- 
goscopy ) 
Swallowing,  mechanics   of  closing   air 
passages  to  food  during,  111 
normal,  bismuth  radiograph   illus- 
trating, 543 
Syncope,  118 

Synthetic  compounds,   56 
Syphilitic  strictures,  intubation  in,  477 
Syi)hlloma      of      trachea      simulating 

tumor,    434 
Syringe,  endoscopic,  for  injections,  41 

468 
Tables.  42,   85 

dropping  of,  122 

for     suspension     laryngoscopy     in 
high  position,  137 
in    ordinary   position,   136 


INDEX. 


Tables,  oiJeiating.  for  suspension  laryn- 
goscopy, 13.') 

French.  43,  i'>,  120 
Table-screws  by  which  changes  of  posi- 
tion are  made.  138 
Tests,  liietin,  107 

Wasserniann,  107 
Thoracic    operature,    upper,    164,    IG.'j, 
171 

disease,  bronchoscopy  in,  4GG 
Thoracotomy.   73.   242,   320-321,  326 
Thymic   compression    stenosis,   47  2-476 
Thymopoxy.  47.'>-476 
Thymus  death,   mechanical   nature   of, 

4"73 
Thyroid   cartilage,  backward   pressure 
of,  for  exposure  of  anterior  commis- 
sure, 106.  124 

forward  pulling  of.    lOii 
tumors,   benign.   433 
Thyrotomic   cases,  after-care  of,   667 
Thyrotomy,  6.5,  66,  93 

for    cancer,    operative    technic    of. 
663 
malignant    disease    of    larynx. 
6.50,   655 
comiilications   in,   668 
dressings  after,  666 
indications  for,  651 
preparation  of  patient  for, 

661 
technic  of.  661-668 

modification  in,  668 
statistic  in,   655-657 
liapilloniata  of  larynx,  424 
or    laryngofissurc,    illustration    of, 
664 
Tongue-spatula,  137,  140,  144 

introduction   of,   144 
Tonsillectomy  under  suspension  laryn- 
goscopy, 151 
Tonsils,  removal  of.  in  cases  of  laryn- 
geal stenosis,  5!iy 

removal  of,  in   patient  with  laryn- 
geal stenosis.  65 
bronchoscopy  in  malignant 

growths  of.  442-443 
deviation  of.  470 

diseases  of.  bronclioscopy    in,   465. 
diverticula  of.   169 
exploration  of.  163 
faulty   incisions   of,   597 
growths    of,    diagnosis    of    malig- 
nant, 442-443 
growth    of,    treatment    of,    malig- 
nant, 443 
incisions   of,   600 

normal  position  of.  79.  81,  160,  185 
relative  position  of  esophagus  and, 

79 
rules   to    be    observed    in    passing 
down,  166 


Trachea,  rupture  of.  subcutaneous,  586 
stenosis  of,  24S 

compression,  470-476,  615 
Trachea   and   laryngoptosis,    deviation 

of,   46S-470 
Ti-eacheal  blast.  162 

incision,  dangers  in,  600-601 

depth  of,  600 
intubation,  75 
pressure,  53 

rings,  obliteration  of,  161,  177 
wall,     endoscopic    appearance    of, 
177 
Tracheitis,  influenzal,  480-482,  484 

subglottic,  edema  following,  116 
Tracheobronchial    tree,    anomalies    of, 
468 

benign  growth  primary  in.  431-435 
lues  of.  485 

positive  lilm  of,  227,  229 
Tracheobronchial  tree,  tuberculosis  of, 

bronchoscopy    in,    485 
Tracheobronchitis,    circumscribed,    476 
Tracheobronchoscopy,  anesthesia  in,  58 
Tracheodernial   fistula,   autoplastic   op- 
eration to  close,   Berger,   642 
Gluck,  642 
Tracheoesophageal    fistula,    congenital. 

493 
Tracheoscopy,  supraglottic  in  children, 

130 
Tracheotomic  cannula,  589-590 

attachment  of  tapes  to,  608-609 
laryngeal  stenosis,  post,  593 
oi)ening.  position  of  second,  594 
Tracheotomizcd    patient,   anesthetizing 

a,  65,  72 
Tracheotomy,   56,   64,    67,    74.     75,    77, 
92,  104,  112.  115.  116.  473.  584-611 
after-care  following,  606-611 
anesthesia  for,  596 
as   a  therapeutic  measure,   584 
asejisis  in,  595 
compUcations   after.  610 
contraindications  to,   5S7 
decannulation  after,  610 
diet  after,  606 
dressings  after.  607 
during     endolaryngeal     oiieration. 

118,  127 
emergency,  602, 
in  dark,  605 
rules   for,  606 
for       compression       stenosis       of 
trachea,    472 
extubation  in  spasmodic  cases, 

613 
foreign  bodies.  584 
malignant  growths  of  trachea, 
413 


IXDKX. 


Tracheotomy       tor      papillomata       of 
larynx,  423 

respiratory  arrest,  584 
subglottic  edema,  265 
hemorrhage  after,  611 
high  versus  low,  592 
in  acute  laryngeal  stenosis,  583 
angioneurotic  edema  of  larynx, 
586 
indications  for,  384-587 
in  foreign  body  work,  215,  287 
laryngeal        hemorrhage        in 
hemophiles,  118 
instruments  for,  45,  588-589 
mortality  of,   587 
nurse  for,  special,  607 
position  of  patient  and  assistants 

for,  595 
preceding    use    of    galvanocautery 

in   larynx,  necessity   for,  117 
preliminary  to   laryngectomy,   671 
preparation  of  patient  for,  595 
prevention   of,   in  laryngeal  tuber- 
culosis, 154 
prior  to  diagnosis,  594 
rapid,  author's  method  of,  603-605 
sinking  of  patient  after,  610 
technic  of,  599 
tray,  contents  of,   609 
Trauma,  55,  86 

during    removal    of    large,    sharp 

body,   179 
laryngeal,  105,  265 
rupture  of  trachea  from  external, 
subcutaneous,   586 
Traumatic  cicatricial   stenosis,   619 
Tube,   insufflation,  size   of,  68 
intratracheal,  75 

T-shaped  soft  rubber,  Killian,  628- 
629 
Tuberculosis,      galvanocaustic,      treat- 
ment of,  116,  205 

laryngeal,  107,  116,  205,  460 

author's  endoscopic  treatment 

of,  116 
Roentgen  ray  in,  154 
suspension     laryngoscopy     in, 
152 
laryngoscoiiy  in  high  dorsal,  85 
of  esophagus,  563 

tracheobronchial     tree,     bron- 
choscopy in,  485 
pulmonary,  53,  234,  248,  300 
advanced,   117 

as    a    contraindication    to    re- 
moval  of  foreign   body,   262 
foreign    body    simulating,    306 
symptoms  in,  absence  of,  486 
Tuberculous    laryngeal    lesions,    extir- 
pation of,  461 
stenosis,  616 

lesions,  direct  laryngoscopy  in  the 
local  treatment  of,  117 


Tuberculous    laryngeal    lesions    below 
larynx,  galvanocautery  in,  117 

perichondritis,  foreign  body  simu- 
lating,  268 
Tubes,  11,  18,  19,  21,  22,  25,  256 
Briinings,  12-14 

preparation  of,  197 
conical  ended,  303 
screw-post,  623 
esophagoscopic,  sizes  of,  194 
intubation.   622 

self-retaining  dilating,  in  situ, 
623 
technic     of     insertion     of     intra- 
tracheal insuiiiation,  68,  70 
work,  anesthesia  in,  54 
Tube-spatula,  Yankauer's  laryngeal,  16 
Tumors  above  cords,  benign  laryngeal, 
removal  of,   110 

below  cords,   removal   of,   106 
large   laryngeal,   schema   illustrat- 
ing    removal     of,     by     ex-tubal 
method.  111 
laryngeal,    removal   of,    107 
on  cords,  removal  of  small,  106 
removal  of,  by  oblique  method,  102 
tracheal,  benign,  symptoms  of,  434 
Turbinotome  for  thyrotomy  and  laryn- 

gotomy,   author's,  633,   634 
Typhoid     fever,     laryngeal     complica- 
tions in,  618 

laryngeal     stenosis     complicating, 
acute,  580 
Ulcerated  forms   of  esophageal   malig- 
nancy, 447 
Ulcer   of   esophagus,   differential   diag- 
nosis of,  496-498 
Vagus  reflex,  60,  103 
Vagus-reflexes,  cocainization  of  larynx 

to   overcome,  148 
Ventricle,  inspection  of,  102 

laryngeal,     removal     of     growths 
from  the,  109 
Ventricular   bands,   60,   188,  236 

accidental  removal  of,  104,   105 
spasmodic    closure    of,    hiding    of 
end  of  forceps  by,  105 
Vision,   field  of,  94,  95 
Vocal    impairment    due    to     laryngeal 
trauma,  105 
nodules,   420 

sessile,    galvanocautery    point 
for  removal  of,  420 
results   after   endoscopic    eviscera- 
tion of  larynx,  113,  114 
after   operation    for   laryngeal 
malignancy,  658-660 
Voice,    buccal,    113 

in  cases  of  larynegal  stenosis,  114 
Vomiturition,  54,  57,  72 
Water  hunger  and  esophagoscopy,   53, 
491,   530 


INDEX. 


XXIU 


Webs  in  upper  third  of  esophagus,  494 
of  larynx,  congenital,  464 

Window-iilug  for  occluding  the  prox- 
imal tube-mouth  when  it  is  desired 
to  l)alloon  esophagus  or  stomach, 
Mosher's,  24 

Abhk,  424 

AliLK    (  Wii.liamixa),    512 

Adams    (James),  480 

ADI.KMAX.  332 

ALriHKCiiT,  135,  136,  137,  141,   149,   151, 

153,  420 
AuitowsMiTH,   337,   565 
Aver,  65,  73,  320 
Bau.enger.  423 
Bak  (Loris),  116 
BAitATorx,  628 
BarlatikI!.  628,  635,  639 
Barndouar.    (W.  p.),  66 
Bakwell,  655 

Bassler    (Anthonv),  501,  506 
Beck.  131,  290 
Berger,  642 
BOET.TER,   222 
BOGGS,  219.  222 
BowEX,  219 
BoYCii   16,  38,  39,  70,  83,   86,  119,   164, 

185,  188,  190,  219,  224.  231,  234,  258, 

300.  302,  307,  308,  312,  470,  481,  483, 

484,  500,  544,  653 
Brain,  143 
Brieger.  135.  154 
BRfix,  525 
BRrEXiNG.s,   12.   13.  14,  17,   28,   36,   55, 

57,  102,  103,   141,  172,   174,  195,  197, 

198,  201,  202,  231,  246,  263,  264,  271, 

275,  296,  303,  304,  519,  539 
Bryax,  91,  581 
BrcilAXAX.  22,  59,  68,  484 
BuTi.ix,  437,  650,  655 
Cagxola,  628 
Canai'EL,   628 

Cari'Exter  (K.  W.),  238,  332,  484 
Cakrel.  65 
Cas.sadiax,  219 
Cassei.rerry,  36,  56,  279 
Chiari,   13.5,  332 
Cr.AAU.  107,  202 

Cr,ARK.  26,  248,  309,  319,  320,  475 
Clayton,  319 
Cohen  (J.  Sous),  659 
Coi.E   (L.  G.),  219,  222 
Cooi.iDGE,  30,  56,  324,  608 
CoTTox.  65 
Crii.e,  73,  5.50 
CiT.nERT,   424 
Ctneo.  651 
Cthtis,  91 

Da   Cosia    (.John    C),   337 
Davis,   64,    135,   247,  255,  461 


65,  66,  69,  73,  320, 


467,    476,    478-480,    484, 


547,  552-555 


673 
467 


Dei-avax.    91,   238,    319,   320,    423,   426, 

439,   465,    622,    653 
De  Saxti  590 
DicKixsox,  15,  19 
Edingtox,  493 
KiMlORN.    19,  21 
Eesuer(;.  60,  61,  64 

450,  661 
Emersox,  337 
Ei'UKAiM,    443 

487 
Eymax,  219 
Fergusox.  669 
Fi;tterhoff,  475 
Foster.  219 
FoiRxiER.  629,  631 
Frkei.axi>.   582 
Frexch,  43,  91,  120 
Frei'Dexthal,  135,  151, 154.  424,  476,  479 
Frieuberg   (Staxtox  a.),  264 
Friedexwai.d.  131 
Froxixg.  135 
Galehsky.  478 
Gati!  (  Otto  C.  ) ,  66, 
Geriieh,  135 
Gereiia.  478 
Gettixgs.  475 
GucK.  642,  662,  669, 
Goldsteix.  290,  421 
GorrsTEix.  237,  239, 
Graeee.  452 

Grant   (Duxdas),  91,  219,  650,  655 
Gray.  219 

Gr  a  V.SOX   (T.  Wray),  521 
Greex    (Horace),  465 
Grier.  219,  222,  293,  295,  360 
GrisEZ.   12,    15,  44, 

452,  468,  484,  490, 

537,  539 
GlTHRIE,  493 

Hacker,  501 
Haiix.  668 
HA.IEK.   116 
Hai.steai).  488,  569 
Hare    (Houart  A.), 
Harmer  (Dovgeas),  441,  655 
1! ARi:is    (Thomas  J.),  424 
Hays.   131 

llEII.ER,    240 

Henderson    (Yanhei.e),  262 

Henke,  135 

Heryxg,  116,  628 

HiCKEY,  219 

Hill,  15,  18,  512,  513,  655 

HixsiiiRG,  135,  276,  303 

Hodge,  576 

HOELSCIIER.   135,   154 

Holding.  219 

Hoi'Maxx.   135 

Horn.  478 

HoRXE    (.loiisox),   665 

HORRO<K,  521 


202,  248,   292,  436, 
492,  507,  524,  525, 


64 


XXIV 


INDEX. 


Howard.    (C.   P.),   299 

HoHSLEY  (J.  Sheltox),  614 

Ho\v.uiTH   (G.),  Ill,  135,  198,  303,  440. 

458,  556,  629,  631 
Hubbard.  3o3 
Hi. XT.  608 
luLAUER,    135,   148,    199,    216,    226,    245, 

299,  326,  538 
IxGALs.  12,  13,  15,  27,  28,  40,  52,  56,  63, 

216,  245,  276,  279,  290,  300,  301,  359, 

467 
ixgersol.  443 
Jaxeway.  65,  73,  320,  450,  568,  569,  577- 

578 
Jekvet.  283 

JoiixsTox   (Geo.  C),  219,  222,  226 
JoiiNSTox   (Richard  H.  ),  16,  18,  85,  86 
JoXES   (Clemext  R.),  521 
JoxES   (E.  L.),  423 
Kahler.  17,  102,  103,  135,  144,  151,  169, 

197,  201,  245,  246,  264,  341,  443,  460, 

468,   171,  485,  546 
K.\tzexsteix,    135,    151,   420 
Keen,  669 

Keith  (Arthur),  540 
Kei.ly    (Browx),    52.      463,    493,    510, 

512,  524,  655 
KiELiAX.  12,  27,  32,  34,  90,  102,  133,  180, 

181,  202,  245,  264,  284,  291,  296,  304, 

324,  356,  424,  465,  466,  541,  569,  635 
KiR.STEix,  12,  17,  27,  28.  79,  81,  102,  133, 

142,  143,  144,  145,  202,  264 
Kleestadt.  135,  151 
Knight  (Chas.  H.),  613 
KoB,  433 
kollicker.  501 
Kov.vcs.  501 
Kyi.e   (D.   Bradfx),  304,  334,  356,  357, 

481 
Lack   (H.  Lamdert),  463 
Lake   (Rkhard),  650,  655 
Laxge,  219 
Lautexschaeger,  135 
Leonard,  219 
Lerche,  521 
Levinger.   433 
Levy.  492 
Lewisohx,  15 
Liebauet.  52,   182,  511 
Lester.  40,  272 
Lockard,  112 
LoEB.  427 

Low   (Stuart),  655 
Lyxah.  620 

Lyxch  (R.  C).  230,  245,  422 
Ma(Fareaxe,  299 
Macheestox.   433 
Mackenzie   (Morrell),  239,  240 
M.\cKixxiE.  524 
I\lAcREyN0LU.s.   494,   523 
Makuen   (Ht-dson),  286 
Manx.   151,  431,  443 


M.VRIXE.  319,  320 

Masterman.  292 

jMathiev,  32 

Mayer   (Emil),   56,  154.  250,   432,   465 

617,  622 
Mayer  (VViei.y),  450,  .538 
Maylarb,  493 
Mazzociii.  424 
McAlli.ster.  512 
McCready    (Homer),  38,  39 
McKee.  68,  39 
McKenzie,  655 
AIehnebt.  52,  178 
Meltzer.  65,   67,  73,  320 
Melzi,  628 
Mexges.  219,  222 
Mermod,  116,  118 
Meyer    (Jes.se),  502,  521 
Mikulicz.  180,  185,  191,  572 
Miller    (Clifton   M.),   614 
MiLLiGAX    (W.),  655 
Millspaugh.  356 

MiTHOEFER.    326 

Molixte,  670,  672 

MosHER.   13,  14,  16,   19,   24,   26,   32,   42, 

52,  56,  85,  195,  262,  269,  353,  443,  519, 

626 
Moure.  66,  632,  650,  655 
MoUEET,  82,  83 


Murphy  (J.  W.),  233,  538 

Mrssox    (Emma   E.) 

,  468,   47 

8 

Neukirch, 

551 

Nowatxy. 

478 

O'Dwyer. 

622,  624 

Paxcoast. 

219 

Parker.  4' 

•6 

Paterson 

(D.    R.), 

32, 

251, 

275, 

352 

354,  360, 

463 

Patterson 

(  Ellen  ) , 

13, 

21, 

28,  51 

,  64 

65,  103, 

216,   256, 

264, 

313 

439, 

455 

483,  588 

599.  608, 

618, 

619 

,  622, 

639 

666,  402 

Peters.  39 

40,  332 

Pfahler. 

219,  222 

Phillips  (Wexdell  C),  16,  17,  21 

Plumjier.    42,    521 

Pollatscheck.   135 

Polyak,  424 

Porter  (W.  G.),  332 

Pratt.  15,  16,  64 

Preobraschexsky,  239 

Price    (H.  T.),  234,  340 

QuiXBY.  65 

Reich.  433 

Reichert.   140,  143 

Rexdi-   (Robert),  577 

Richards    (Geo.  L.),  40,  234,  290,  301. 

476,  614 
Richardson,  290 
RoBixsox.  65 
Roe,  319 
Rogers    (.Tonx).   624 


INDEX. 


XXV 


Rose,  79,  80,  119,  190,  202,  264 

RoSK.Now.  570 

Ross,  576 

ROVGKT.    511 

RuG(ii.  628 

Sajous.  58,  64 

SAN-nKit    (Fhank   D.),   56 

SAi!(iNo.v.  262,  292,  500,  628,  635,  639 

Saiki!.  432 

Schmidt    (Mohitzi,   91 

Scn.Mii:uKi,o\v,  624 

SCIIOO.NMAKKI!,    13 
SCIIIIOKTTKI!    (\\),    240.   4;!1 
Sciiwi.NX.  476 
Skkt.ic.  444,  445 

Sf:iii-i:i!T.  135,  144,  147,  148,  151,  154 
Skmon.  91,  108,  240,  338,  424,  437,  442, 
542,  650,  655,  667 

Sl.'MOI.KKI,    135 

Simpson,  91,  234,  622 

SiPPKY.  537 

Sr.iDKu  (Grekxfiki.d),  334 

Smith    (Hahmo.n),   267,  424 

Smith   (Wm.  Biuck),  241 

Snow.  241 

SOITHKBLAM)    (G.    A.),    463 

Spikss,  431 

Staiu  K,  550 

STiaiF.  576 

Stkix    (Otto),  433 

Stf.inf.r,  135,  154 

STErnx,  544 

Stoerk.  501 

Stokat.  135 

Sti-cky    {.Ioskph  a.),  64.  238.  425,  427 


Stucky    (  Wii.i.iam  I.   64 
Swaix,  91,  617 

SYLVKfSllOR,    585 

Symoxds    (Chautkus),  451-452 

Taunz.  485 

THiiisEX.  443 

Thomp.sox    (.John  A.),  421 

Thomson  (St.  Ci.ahi),  91,  240,  292,  329- 

330,  420,  422,  463,  648,  650,  655,  659, 

663 
Thost.  629 
TiLLEY,  91,  199,  219,  290,  292,  561,  650, 

655 
Tod  (Huxter),  655 
Todd.  233 

Trexdeeexderg.  66,  78,  287,  668 
Trotsseav.  599,  604,  609 
TiRNER   (Lor.Ax),  263,  .580,  655 

VltiXARD,    628 

Vox  Ekkex.  90,  181,  227,  234,  239,  245, 

263,  432,  485 
Vox  S<-hroetter.  261 
Wadmack.  433 

Waggette,  96,  195,  251,  337,  483 
VVeixgaertxer,   148 
Weli..'^.  421 

Williams   (Watsox),  655 
Wixsi.ow,  56,  292 
WOLIE,  135,  151 
Wood   (Geo.  P.),  238,  319 
Woods  (Sir  Rorkrt),  433,  442,  673 
Wright   (Joxatiiax),  107 
Wylie.  420 

Yaxkai-er.  16,  28,  41,  5G,  279 
Zenker.   180,  ..41 


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